
Class 
Book 



MknU 



Copyright)^". 



COPlfRIGHT DEPOSIT. 



INSURANCE 
MEDICINE 



BEING 



Suggestions to Medical Examiners 



By 
HENRY H. SCHROEDER, M.D. 

Medical Director, Mutual Life Insurance Company of New 
York; Editor Insurance Department, Medical Record. 



Reprinted from the Medical Record. 



NEW \^ORK 
WILLIAM WOOD AND COMPANY 

MDCCCCXIII. 



<^ 






Copyright, 1913. 
By WILLIAM WOOD & COMPANY. 



©CI,A343986 



CONTENTS 



PAGES 
Introductory Remarks r 

General Considerations 4 

Tact and Judgment 4 

Time and Place of Examination 7 

Methods in Examining 9 

Incomplete Information 14 

Hygienic Surroundings 17 

Occupation 20 

Personal History 2^ 

Family History 62 

The Physical Examination 67 

The Urine 117 

Examination of Women 130 

Completion of the Examiner's Report 134 

Fraudulent Practices 146 



111 



PREFACE 



The favorable reception accorded the series of 
articles entitled ''Suggestions to Medical Examin- 
ers'' which have appeared during the past eighteen 
months in the Medical Record has encouraged the 
writer to collect them in book form. It was the 
purpose of these articles to present the subject in a 
way that would tend to establish a feeling of con- 
fidence between the home office and the field forces — 
in other words, to bring into closer touch the medi- 
cal directors and medical examiners and to discuss 
the everyday practical points which are of in- 
estimable value to the active worker. The articles 
comprise the results of twenty years of experience 
as examiner and medical director, and the author 
trusts that the book will supply the special knowl- 
edge which is so essential to the efficiency of the 
peculiar duties of medical examiners. 



INSURANCE MEDICINE 

INTRODUCTORY REMARKS. 

The quality of the work achieved by medical men 
interested in life insurance has not failed to share 
in the advance of general medicine, and it nat- 
urally follows that the medical directors are alert 
in securing better information and expect more 
efificient service than would have been possible 
in the earlier days of life insurance. These 
two bodies of men, the home office staff and the ex- 
aminers in the field, have hitherto worked apart, and 
in order that they may be brought nearer to each 
other for a mutual exchange of ideas, it is pro- 
posed to devote space in this column to a series of 
contributions from those who have made this subject 
their life work. There was little to say in the old 
days when the companies were sm^aller, th« examin- 
ers fewer in number, and the vast amount of valua- 
ble material in possession of the companies had not 
been threshed out. Even the home office staffs had 
not learned fully to realize the importance of the 
great quantities of valuable material lying dormant 
on the shelves. During those years the business of 
life insurance was conducted on profitable lines, but 
as competition became keener it behooved each com- 
pany to do its best to keep up with the rival con- 
cerns. A more potent factor, however, than the 
prodding of competition was the natural progres- 
sive spirit of those to whom the welfare of the va- 
rious companies was intrusted. As the experience 
of each company was gradually worked out, it be- 
came evident from time to time that considerable 
modifications of the old views were needed. In get- 



INSURANCE MEDICINE. 

ting at these facts the companies did not work to- 
gether. On the contrary, each one had its own corps 
of trained assistants and retained nearly all the in- 
formation gained through its efforts for its own in- 
dividual use. As time has gone by, however, a ten- 
dency has grown toward an interchange of views 
between the representatives of the companies, and 
there is now more than ever a combined effort to 
base the selection of risks on a definite and scientific 
foundation. This is found to be especially true of 
the medical and actuarial officers, and has been ef- 
fected through the meetings of associations devoted 
to their special interests. These meetings have been 
profitable to the members, but there has been a very 
limited distribution of the proceedings among the 
general profession. While, then, a large amount of 
w^ork has gone on and important results have been 
obtained, the field worker has had but little oppor- 
tunity to derive much benefit from them. 

The only practical way to reach the medical ex- 
aminer is through the columns of a regular medical 
publication to which all contributors have equal 
access. Previous attempts in this direction have 
been either unwisely directed, or sporadic and short 
lived. The text books for life insurance examiners, 
while some of them are excellent, necessarily treat 
the subject in a more or less didactic way, many of 
the everyday but important practical points being 
outside of their range. It will be the object of a 
series of informal contributions under the head of 
''Suggestions to Medical Examiners" to present not 
only the practical side of insurance medicine, but 
also to explain the meaning of many of the require- 
ments of the home office. It is frequently found 
that an examiner is at a complete loss to understand 
why certain additional information is wanted. As 
an examiner, he has had to work out his own salva- 
tion, assisted only by brief, concise communications 
from members of the busy home office staffs, too 
pressed for time to explain the bearing of their re- 
quests. Like other people, medical examiners dislike 



INTRODUCTORY REMARKS. 

to work in the dark, and it is not a cause for wonder 
if they sometimes fail to grasp the point and even 
show signs of irritation over, what seem to them, 
useless questions. The conditions under which they 
follow their general practice differ widely from 
those which confront them as examiners, and it is 
only fair to them to take advantage of every oppor- 
tunity to make them more familiar with the many 
intricacies involved in modern methods of selecting 
risks for life insurance. By the possession of a more 
complete understanding of the subject, they will 
recognize the importance of the requests from medi- 
cal directors, many of which formerly seemed un- 
reasonable and even irrelevant, and furthermore 
they will make their examinations with the demands 
of modern life insurance in mind, thereby lessening 
the call for subsequent communications from the 
main offices. And, still further, when the requests 
for additional requirements do come, they will 
cheerfully give the extra services called for. If suc- 
cess is attained in bringing the forces of the home 
office and the field closer together, in bringing them 
to work harmoniously, and in augmenting the good 
feeling already existing, the labors of both will be- 
come lighter and more pleasant. 



Chapter I. 

GENERAL CONSIDERATIONS. 

The rules of ethics and policy play an important 
role in examining for life insurance, and an ob- 
servance of them, as far as circumstances allow, 
will not only smooth the path of the examiner but 
help satisfy the other parties concerned. It will 
not be out of the way, therefore, to offer a few sug- 
gestions on these lines before taking up the subject 
from a purely medical point of view. 

TACT AND JUDGMENT. 

The two attributes, tact and judgment, are in- 
valuable assets to every professional and business 
man, and are particularly useful when a physician 
is acting in the capacity of medical examiner. Suc- 
cess has only too frequently come to those who, 
though deficient in medical training and skill, have 
been the possessors of these admirable qualities ; 
and then others, though adequately equipped and 
brainy, have not prospered because they would not 
or could not handle their clients and fellowmen wnth 
the requisite amount of tact and judgment. The 
successful life insurance examiner most highly ap- 
preciated by his company is the one who, while 
quick, skillful and firm in his decisions, retains the 
respect and good will of the applicant and agent 
through his courtesy and ease of manner and who, 
furthermore, can be counted upon to calm the 
ruffled feelings of an irritated applicant or regain 
the good will of a discontented policy holder. 

The management of the average applicant is a 
delicate proposition, for as a rule he does not seek 



GENERAL CONSIDERATIONS. 

life insurance and has probably yielded to the per- 
suasion of the agent after a long and persistent 
struggle. Later on he is apt to be thankful at what 
he considers his own foresight in throwing this 
protection about his family, but, for the time being, 
he may be very reluctant in submitting to the ex- 
amination — not anxiously seeking it as an examiner 
will sometimes suppose. Even if he had any en- 
thusiasm in the beginning, his ardor may become 
chilled at any stage during the preliminary steps 
required before a policy can be placed. The ex- 
aminer has little opportunity for previously study- 
ing the mood of each applicant, of knowing whether 
he is to meet a willing or unwilling subject, and he 
should, therefore, take it for granted that each 
case will present its individual difficulties and that 
the subject may be more or less sensitive to brusque 
or impatient treatment. The applicant may go fur- 
ther and display an unwilling and disobliging spirit ; 
at such a time it is doubly important for the ex- 
aminer to be diplomatic rather than show signs of 
irritation and perhaps cause the agent to lose the 
business. The strong, able examiner always keeps 
absolute control over his feelings, no matter how 
provoking the circumstances may be, whereas the 
weak will give way. The wrong word from an 
examiner in an unguarded moment has cost the 
agent the loss of many long days, even weeks, of 
trying, arduous work. An examiner should always 
remember that there are others — the company and 
the agent — whose financial interests in the matter 
are greater than his own, and for this reason he 
ought to ignore the occasional inconvenience and 
trouble he may encounter. Furthermore, it should 
be his endeavor to leave the applicant and agent 
good friends to himself and the company, even when 
it is his unpleasant duty to ^ive an opinion adverse 
to their interests, for not onlv will he then serve the 
company better, but, also, will add to his own popu- 
larity in the community. 

Notwithstanding what has been stated in regard 



INSURANCE MEDICINE. 

to the importance of keeping up agreeable relations 
with the agent, it should always be distinctly under- 
stood that the examiner is to elicit a full history 
from and make a careful examination of the appli- 
cant without allowing the agent to interfere or in- 
trude to the slightest degree. A company cannot 
conserve the interests of its many policy holders 
without insisting on careful work by mipartial and 
uninfluenced examiners and on rigidity in selection. 
The examiner must be decidedly firm in this re- 
spect, and his ability to do so and at the same time 
remain on pleasant terms with the agent and appli- 
cant correspondingly increases his value as a medi- 
cal representative of the company. 

While in a general way, tact, and judgment should 
be observed at all times, they are especially called 
for whenever some unavoidable emergency inter- 
feres with promptness in keeping the appointment 
as to time and place, in propounding the many 
pointed questions in regard to personal and family 
history, in inquiries concerning the use of alcohol 
and drugs, when requesting the applicant to re- 
move sufficient clothing to allow a thorough exam- 
ination, in the examination of women especially 
when interrogating them about the functions and 
diseases peculiar to their sex, and in procuring sub- 
sequent additional information. 

The examiner with small experience may hesi- 
tate to completely carry out some of the require- 
ments through fear of upsetting the mental equi- 
librium of the applicant. That all the demands 
and queries can be made when diplomacy is em- 
ployed and not give rise to irritation, is proved by 
the experience of the carefully picked examiners 
on duty at the home offices. They come in con- 
tact with applicants only found in the large centers 
— the leaders in industry and finance, powerful and 
forceful — men having heavy demands on every min- 
ute of their time, and accustomed to rule their fel- 
low beings. They are difficult to approach, and it 
w^ould be natural if they chafed in submitting to 



GENERAL CONSIDERATIONS. 

the full requirements which are invariably exacted 
by these examiners. Yet, the latter, through their 
quick appreciation of what is fit, proper and right, 
secure the cooperation of the applicant and carry 
out their mission thoroughly from beginning to end. 

THE TIME AND PLACE OF EXAMINATION. 

The time and place of examination may be dis- 
cussed from two points as viewed separately by the 
agent and the examiner. 

The agent considers the convenience of the appli- 
cant in making the appointment for the examina- 
tion. If, in his anxiety to close the deal, he may 
occasionally go so far in trying to please his appli- 
cant as to make arrangements prejudicial to the 
interests of the company, he should not be criticised 
too severely, for even after he has induced his ap- 
plicant to sign the application after some very hard 
work, he understands only too well that the latter 
may experience a change of heart at any minute 
through misgivings and lack of conviction, or he 
may be persuaded by friends to seek insurance else- 
where, or yield to a tempting offer from a rival 
assent before the transaction is consummated by 
the payment of the premium. It is therefore most 
important to him that the arrangement decided on 
be promptly and efficiently carried out by the ex- 
aminer or, if any change is thought advisable, that 
he be notified by the examiner at once. In the 
event of failure to finally place the policy, the agent 
is naturally apt to blame the examiner if, perchance, 
the latter has not strictly observed all details of the 
appointment, especially in regard to the time agreed 
upon. 

The examiner naturally prefers that the appli- 
cant be brought to his office, not solely to make his 
own work easier, but rather because the con- 
ditions there are more favorable for a thorough 
examination than those found at the residence or 
place of business of the applicant. It is a good idea 
for the examiner to suggest this to the agent, and 



INSURANCE MEDICINE. 

the latter will usually cheerfully agree to do so 
whenever the circumstances permit. If, however, 
the agent finds he cannot meet this wish through 
the unwillingness of the applicant or because he has 
such a slight hold on him that he does not dare take 
any chances, the examiner will assist him and 
facilitate his work by attending promptly to what- 
ever appointment is made. 

Promptness is most highly appreciated by both 
the agent and the company, as a certain amount 
of business is lost through delays from dif- 
ferent causes, the amount being so large, in fact, 
that the examiner cannot be advised too strongly 
against failing to meet the applicant exactly at the 
time arranged for, even if a change as to place has 
been made in accordance with the exceptions re- 
ferred to later on. 

Occasionally, especially in small places where 
all are more or less acquainted with each 
other, the examiner will be on friendly enough 
terms with the applicant to venture on tactfully sug- 
gesting that the necessary requirements can be ful- 
filled more comfortably and satisfactorily at his 
office, in case it has been arranged to have the ex- 
amination at the applicant's residence or place of 
business. The companies prefer to have examina- 
tions made at the examiner's office whenever pos- 
sible, having in mind the greater privacy, absence 
of noise, and the creation of a more confidential 
frame of mind in the applicant. The examiner, 
however, should never attempt to transfer the field 
of operation to his office unless he is quite sure of 
his ground, as the changing of the plans of the 
agent is a delicate matter. We would particularly 
advise the examiner not to request the applicant to 
call at his office and then wait for him to come re- 
gardless of the time already set for the engagement, 
as such a course is almost sure to lead to friction 
with the agent. If for some good reason the exam- 
iner believes that another place should be chosen or 
if he finds himself unable to keep the appointment, he 

8 



GENERAL CONSIDERATIONS. 

would better notify the agent to change the arrange- 
ment to a more acceptable one rather than to assume 
the responsibiHty himself. Furthermore, if the ex- 
aminer knows that he cannot carry out the plan 
adopted by the agent, it will lead to a happier rela- 
tion between them if the former explains this when 
the application is presented. 

It is the earnest wish of the medical directors, 
generally, to have all examinations made under 
conditions which are favorable to precise and com- 
plete findings. If, then, an examiner learns that 
the examination is to be made with so much noise 
and bustle about that it will amount to nothing more 
than a farce, his action will be upheld if he insists on 
the selection of a suitable place, free from noise and 
intrusion. In addition to quiet there should be pri- 
vacy, and if this is not possible at the appointed 
place, the examiner should not hesitate to request 
some other arrangement. He will usually, however, 
by the exercise of a little tact, succeed in securing 
the desired privacy at the appointed place. The pri- 
vacy should be complete, and this means the 
exclusion of any third person, no matter how closely 
related, and also the agent. In the event of the 
applicant being a woman, the husband or a woman 
friend may be present during the physical examina- 
tion, but this should never be permitted while asking 
the questions on the application blank. The ex- 
aminer will readily understand the importance of 
privacy in the examinations, as he is aware that 
some of his questions will be of such a personal 
nature that they may not be frankly answered in 
the presence of a third person. He knows still 
further that he will need the help of privacy to gain 
the complete confidence of the applicant before he 
can elicit certain kinds of information which appli- 
cants are prone to conceal. 

METHOD IN EXAMINING. 

The examiner will execute his mission with 
greater facility and expedition and the quality of 

9 



INSURANCE MEDICINE. 

his work will redound more to his credit if he culti- 
vates system and method in his examinations. 
While the examination blanks are framed to assist 
him in this respect, they must necessarily be com- 
pact, and on this account it is impossible to incor- 
porate references to every conceivable contingency. 
It frequently happens that an important point de- 
velops in the case which is only referred to on the 
application in a general way, or perhaps not men- 
tioned at all, and yet, in order to present a complete 
report, it is imperative that this point be described 
fully and in detail. The company must, therefore, 
rely upon the acuteness and observation of the ex- 
aminer to ferret out complete information, whether 
asked for on the examination blank or not, and to 
give all particulars obtainable. It is not pleasant 
for an examiner to discover that he did not in- 
clude certain facts in his report because they were 
not called for on the blank. The only way for him 
to cover every point and get a full, rounded report 
is to invariably follow some definite plan, calculated 
to accomplish this object with thoroughness and 
despatch. The following synopsis is one which will 
aid an examiner, and if this, or a modified form to 
suit the individual taste or the special blank of the 
company represented, is observed in every examina- 
tion, the ground will be well covered, though even 
then some situation not included in this scheme will 
come up occasionally. In this skeleton sketch brev- 
ity has not been sacrificed for the discussion of de- 
tails, especially as it is planned to take up each sub- 
ject referred to later on. 

Hygienic Surroundings. — Anything unhealthful 
or unsanitary in the house or immediate surround- 
ings? 

Occupation. — Unhealthful or dangerous? Is it 
stated correctly in the application? 

Moral Hazard. — Is the insurance speculative? 
What is the insurable interest of the beneficiary? 
Is the amount applied for warranted by the state of 
finances ? 

10 



GENERAL CONSIDERATIONS. 

Personal History. — Note — The examiner will 
not get explicit answers unless his questions are ex- 
plicit, specific, and insistent, but always with 
patience and tact. General questions will only 
bring out generalities and evasions, especially when 
the applicant is disposed to keep back certain facts 
or underrate their importance. In order that the 
information gained from these questions may be 
complete, it should invariably comprise the name of 
the disease, number of attacks, the cause, duration, 
severity and remaining effects of each attack, and 
the date of the last attack. 

Nervous System, — Any dizziness, fainting spells, 
unconsciousness, convulsions? If so, any suspicion 
of epilepsy ? Also, any insomnia, insanity, apoplexy, 
paralysis ? Any history of headaches, nervous pros- 
tration, neuralgia, tremor, sunstroke? 

Circulatory System, — Any palpitation, heart trou- 
ble, varicose veins, pain in the region of the heart? 
Dropsy ? 

Respiratory System. — Chronic or persistent cough 
or hoarseness, spitting, or coughing of blood? (Al- 
ways report spitting of blood no matter how trivial 
or what the alleged source may be.) Any bronchitis, 
pleurisy, pneumonia, consumption, asthma? Sub- 
ject to frequent colds? 

Digestive System, — Any dyspep^^ia, indigestion, 
biliousness? If so, always ask if there was any 
suspicion of appendicitis, gallstones, or renal colic, 
and report the answer, whether negative or affirma- 
tive. Any hematamesis, appendicitis, intestinal colic, 
diarrhea, hepatic colic, jaundice, disease of the liver, 
hemorrhoids, fistula, tape worm? 

Genito-urinary System. — Any disease of the kid- 
neys, pelvis of kidney, bladder, prostate, testicles? 
Any renal colic, dropsy, hematuria, frequent urina- 
tion, stricture of the urethra, hydrocele? 

Unclassified Diseases, — (So called in insur- 
ance medicine as a convenience.) 

Malarial and Other Fevers. — If malarial, state 
whether intermittent or remittent. Any hematuria? 

II 



INSURANCE MEDICINE. 

Rheumatism. — Articular or muscular? Number 
of attacks, parts affected in each? Date and dura- 
tion of each? Heart involved? 

Gout. — Very important to report number of at- 
tacks, parts affected, severity, and whether any 
symptoms between attacks. 

Syphilis. — Date of initial lesion and secondaries? 
Any tertiaries? Date of last manifestation and 
treatment ? 

Abscess or Ulcer. — Full history. Any suspicion 
of tuberculosis, malignancy, or syphilis? 

Skin. — Syphilis, tuberculosis, or malignancy? If 
erysipelas, number and dateo of attacks ? 

Nose. — Chronic catarrh ? Polypi ? 

Ear. — Full details of any discharge, whether 
acute or chronic. 

Scrofula, SwelHng or Suppuration of the Glands. 
— ^Tuberculosis, any suspicion of? 

Surgical Operations. — Full details. Any sus- 
picion of malignancy or tuberculosis? 

Habits. — Drugs? More difficult to get history 
than when alcohol used to excess, also more im- 
portant. 

Alcohol? Amount daily consumed, and the most 
used in any one day? Ever to excess? If so, fre- 
quency, duration of periods, and date of last ex- 
cess? Ever take any cure? If so, date? 

Family History. — Fill out as required on blank. 
Give specific causes of death and omit terms such 
as '^Don't know," ^^Natural causes," ^'Debility/' 
"Childbirth," and ^'Change of life'' whenever pos- 
sible. Any tuberculosis in immediate household 
during past year? If any death from tuberculosis, 
give date. 

Physical Examination. — For the physical ex- 
amination, the applicant's chest and abdomen should 
be bared. This is easily accomplished by removal 
of coat, waistcoat, and suspenders, and then rolling 
up both shirts. 

General Appearance, — Healthy or unhealthy? 
(Do not use the term "Fair.") If pale, state 

12 



GENERAL CONSIDERATIONS. 

whether due to anemia or ill health, or solely to 
indoor occupation or natural color. Jaundice, 
marked sallowness, or evidence of dissipation? 

Apparent Age. — As stated or older? 

Race, — White or Caucasian? Negro? Indian? 
Do not answer by giving nationality. 

Weight. — Ascertain by scales if near or beyond 
the limits set forth in table. If excessive, is it due 
to fat? If light, is applicant wiry or subject to 
some ailment or recent illness? 

Measurements of Chest and Abdomen. — Ascer- 
tain by tape on bare skin. If abdominal measure- 
ment is excessive, is it due to fat or tumor? 

Pulse. — Count before examining, as it may be- 
come rapid, intermittent, or irregular merely from 
excitement. 

Arteries. — Thickening or atheroma? High ten- 
sion? Take blood-pressure if apparatus is at hand. 
Possibility of aneurysm should not be forgotten. 

Heart. — Size, sounds, position normal? Differ- 
entiate functional and organic murmurs. 

Lungs. — Special attention should be given to 
apices, as any tuberculosis met wdth is usually in 
the initial stage. Note any huskiness of voice and 
the number of respirations. 

Liver and Spleen, — Map out size and location. 
Any tenderness ? 

Hernia. — Reducible? Is it supported by proper 
fitting truss? 

Thyroid Gland. — Small goiters often missed. 
Any exophthalmos or nervous symptoms? 

Nervous System. — Test pupillary and patellar re- 
flexes. Any tongue tremor? Is speech normal or 
hesitating? Are pupils equal in size and are they 
contracted or dilated? Have applicant walk and 
observe gait. If any tremor of hands, is it due to 
organic disease or to nervousness or illiteracy? 

Eyes and Ears. — Any impairment of sight or 
hearing? Ordinary errors of refraction corrected 
by glasses not worth noticing. If any discharge 



INSURANCE MEDICINE. 

from ear, is it serous, purulent, bloody, or of- 
fensive? Any tophi signifying gout? 

Skin. — If any disease, parts affected and extent? 

Mouth, Teeth, and Tongue. — Any signs of diges- 
tive disturbances, syphilis, or nervous disease? 

Deformities. — Curvature of spine? If any, is it 
lateral of anteroposterior? Give accurate idea of 
deviation. If hip disease, are there any scars and 
how much shortening? Describe and gi\e history 
of any other deformity. 

Urine should be passed in clean vessel in presence 
of examiner. 

Women. — All the questions in the blank referring 
to women should be asked, whether she is single 
or married. Corsets and all clothing except a thin 
waist should be removed from chest. 

INCOMPLETE INFORMATION. 

A SPECIAL contribution on this subject is warranted 
in view of the difficulties experienced by the mem- 
bers of the home office staffs in securing full and 
complete reports. The busy practitioner, usually 
pressed for time, is too apt to make life insurance 
examinations with all possible haste, thereby miss- 
ing important facts which a more searching in- 
quiry would elicit, or forgetting to record the 
answers to his inquiries in his report, all of which 
would probably be obviated if sufficient time were 
allowed. 

An application, when signed and witnessed, be- 
comes part of a regular contract, and it is not 
properly executed until each and every question is 
fully and correctly answered. It is the duty of the 
company to see that all requirements are satisfac- 
torily fulfilled before allowing the release of the 
policy, especially for two reasons, viz., to protect 
the interests of those already holding policies by 
acquiring all possible information before assuming 
new risks, and to prevent any misunderstanding 
and chance for future trouble with the applicant 
himself in the event of the acceptance of his appli- 

14 



GENERAL CONSIDERATIONS. 

cation. In order that this duty may be faithfully 
carried out, it is imperative to correspond with the 
examiner until all omissions, errors and incomplete 
information are properly supplied and corrected. 

In a certain company which keeps careful records 
of the work of each of its examiners, an analysis 
of loo cards taken at random from the files shows 
that in 1,279 consecutive examinations there were 
239 in which omissions in answering the questions 
and 319 in which incomplete answers were found. 
As a result of such omissions and incomplete 
answers, the records in the same company show 
that about 50 per cent, of all applications reviewed 
by the approving officers during the year 1910 had 
previously passed over their desks one or more 
times, and were brought up again for further con- 
sideration on receiving information it had been 
necessary to ask for before final action could be 
taken. It is quite apparent from this statement that 
in order to correct these omissions and incomplete 
answers, the companies are compelled to conduct an 
enormous amount of correspondence and that there 
is a consequent heavy expense, much extra labor, 
and a great loss of time. Furthermore, the ex- 
aminers themselves are put to considerable and un- 
necessary additional trouble in subsequently pro- 
curing missing information which could have been 
obtained when making the original examination. 
It may be added that, according to the records, ex- 
aminers otherwise of undoubted skill may be num- 
bered with those whose reports exhibit signs of 
haste and insufficient care. 

Aside from the burden and expense to the com- 
panies, the delay resulting from the necessary cor- 
respondence gives rise continually to irritation on 
the part of the agent and applicant. The agent has 
learned from sad experience to dread delay in his 
business as it gives time for a change of heart 
in the applicant and a chance for his ever-ready 
rivals to wrest the results of his long-continued 
efforts away from him. Consequently he complains 

15 



INSURANCE MEDICINE. 

bitterly as soon as any obstacle tends to interfere 
with the prompt issuance of the policy. Realizing 
the difficulties of their solicitors in procuring 
business and finally placing the policies, the com- 
panies exert every energy to expedite and facili- 
tate their work, though they continually find their 
efforts baffled through the receipt of incomplete 
information. 

Examiners do not willingly and knowingly par- 
ticipate in causing all the troubles enumerated in 
this article. The individual examiner, when writ- 
ten to for some facts or details that should already 
have appeared in his report, will seldom realize that 
his shortcoming is one of very many. He is almost 
always eager to supply the missing data promptly, 
but even at the best he has caused a certain amount 
of inconvenience and delay. He has never had a 
good opportunity to learn how vast the proportions 
of these omissions and incomplete answers assume 
in the aggregate, and it would not occasion any 
wonder if he were to continue in the belief that 
these delinquencies are, after all, unimportant and 
of only occasional occurrence, unless he is enlight- 
ened in regard to this too common lack of thor- 
oughness by some one in a position to speak intelli- 
gently on this subject. 

The subject has been presented frankly with the 
confidence that every examiner who reads these 
lines will be glad to arrive at a better understand- 
ing of the situation and to exercise the utmost care 
and precision in making up his reports in the future 
if he has not already done so. The following sug- 
gestions are offered, as an observance of them will 
obviate much of the trouble referred to: 

1. Allow sufficient time to make a thorough ex- 
amination and careful inquiry. 

2. Each question should be asked separately and 
the answer recorded at once. 

3. Avoid the use of vague terms, such as ''fair,'' 
"moderate," "child-birth," "change of life," etc. 

4. Whenever the question can be answered in- 

16 



GENERAL CONSIDERATIONS. 

telligently by "yes'' or 'no," these incisive mono- 
syllables should be used rather than a lengthy 
answer, which may not be clearly understood. 

5. When recording an illness, in addition to giv- 
ing a clear description of the ailment, furnish a 
definite statement of the dates, duration of each 
attack if more than one, frequency of attacks, 
complications, and the date of last occurrrence and 
after effects. 

6. An applicant will sometimes evade the ques- 
tion. This may be due to inability to concentrate 
or to a desire to conceal certain facts. The appli- 
cant will try to turn the conversation to othor sub- 
jects, but the examiner should come back to his 
question, easily and tactfully, but persistently, until 
he has secured a definite answer. 

7. Before forwarding the papers to the company 
always scrutinize the application carefully so that 
any omitted or incomplete answers may be discov- 
ered and corrected. 

HYGIENIC SURROUNDINGS. 

The question of hygienic surroundings is about the 
first to excite the interest of the examiner upon his 
arrival at the appointed place and he usually has an 
opportunity to look around while waiting for the 
applicant to appear. An individual who is willing 
and able to apply for life insurance is so apt to un- 
derstand and observe the laws of hygiene that the 
examiner, as a rule, pays but little attention to the 
sanitary surroundings of the applicant. The unsatis- 
factory conditions described further on are encoun- 
tered at times, however, and it is therefore not a 
good idea to take it for granted that the environment 
is always above criticism. While the examiner can 
only make a personal investigation, as a rule, at the 
place where he meets the applicant, he ought to in- 
quire into the sanitary conditions existing at the 
residence or place of business, as the case may be, 
or in regard to both places, if the applicant comes 
to the examiner's office. 

17 



INSURANCE MEDICINE. 

Residence. — Applications numerous enough to ex- 
cite comment are received from persons living in 
quarters which, by reason of the squalor, filth, and 
overcrowding found there, are so distinctly unsani- 
tary that the occupants become undesirable risks. 
These applicants are usually found among the for- 
eign elements of the population in the larger cities. 
Their one and only idea is the accumulation of 
money, and they are absolutely ignorant of or in- 
different to the most ordinary laws of hygiene. Yet, 
strange as it may seem, they are keenly alive to the 
advantages derived from life insurance and willing 
to pay for it. Such people may, furthermore, be 
counted upon to choose food unfit to eat and more 
or less devoid of nourishment. We are frequently 
assured by the agents that these people live to a 
ripe old age in spite of their habits and environ- 
ment, but the fact that a few patriarchs are found 
among tjiem is easily explained by the law allowing 
the survival of the fittest. To prove how little 
foundation there is to such statements, we only have 
to remember that there are quite a number of au- 
thenticated records of individual negroes living con- 
siderably over lOO years of age, yet recent statistics 
of the city of Washington gave a death rate of 2y 
per thousand among the colored people, while that 
of the v/hites is 15 per thousand. After all has 
been said, however, it remains true that human be- 
ings can exist under unfavorable circumstances, 
provided the conditions are not altogether bad, and 
the examiner will, therefore, have to make careful 
observations and then exercise his judgment as to 
whether or not he should recommend the risk. The 
presence of tuberculosis or other infectious diseases 
and the hygienic measures adopted for the protec- 
tion of others should be fully reported. 

Place of Business. — It is not unusual to find work- 
ers horded in places, especially the sweat shops and 
junk shops, which are so overcrowded, badly ven- 
tilated, damp, and poorly lighted that their health 
is liable to become impaired. The applicants met 

18 



GENERAL CONSIDERATIONS. 

in such places are usually in the class described in 
the preceding section. The objectionable condition 
may be due to the occupation rather than to lack 
of sanitation, but as the companies have investigated 
the subject of occupation carefully and instituted 
certain restrictions, the examiner will seldom 
have to take any action other than noticing if the 
occupation has been correctly given in the applica- 
tion. Nevertheless, if an applicant is found ex- 
posed to any condition liable to prove dangerous 
to life, such, for instance, as the presence of nox- 
ious fumes, or an excess of metallic or other in- 
jurious dust, the facts should be incorporated in the 
medical report. 

The Locality, — In the cities and towns, about the 
only adverse conditions threatening the whole com- 
munity are the rare but violent epidemics of ty- 
phoid, yellow fever, and other contagious diseases. 
Owing to the better understanding of preventive 
measures, the authorities are able to adopt the 
proper and effective precautions. While, then, 
epidemics of these diseases seldona assume so grave 
an outlook as to warrant the companies in even 
temporarily ceasing to accept business from the 
affected locality, nevertheless it remains for the 
examiner to advise the home office of the existence 
of any epidemic and as to whether or not proper 
sanitary and preventative measures are taken by the 
applicant. In the country and small villages the lo- 
cal organization for putting preventive measures 
into force may be too limited to insure complete and 
satisfactory results, so that it will be better in the 
rare instances in which this condrtion is likely to 
appear, to report it. 

Last, and perhaps the most important, especially 
in the South and Southwest, is the prevention of 
malaria by means of dra,inage and screens. Through 
these two measures a great deal has been accom- 
plished in preventing the propagation of the ma- 
laria-bearing mosquito and the entrance of these 
insects into the house. Manj people are careless, 

IQ 



INSURANCE MEDICINE. 

however, and when the applicant is a resident in a 
district where malaria of a severe type is known 
to occur, vigilance should be exercised in noting 
the surroundings, the presence of unscreened rain 
barrels and other vessels holding water, and 
whether or not the house is properly screened. 

OCCUPATION. 

The examiner should always notice carefully 
whether the occupation is correctly and definitely 
described in the application and report any derelic- 
tion. This precaution is a most important one, 
as it may be discovered that, in addition to the 
occupation as stated in the application, the ap- 
plicant is engaged in some way in handling, selling, 
or manufacturing alcoholic beverages. The occu- 
pation may only appear in such cases as that of 
hotel keeper, merchant, or proprietor of a store, 
etc. Having cleared up this point beyond all doubt, 
the examiner may usually leave the matter for the 
further consideration of the home office, as every 
company has adopted its own classification of the 
relative influences of the various occupations on the 
duration of life in general. In some cases, how- 
ever, it becomes his task to determine how far the 
applicant's particular employment may affect his 
individual longevity. One man may be so consti- 
tuted that, though just at or possibly a little below 
the average physical condition, he is safely insur- 
able provided all the circumstances connected with 
his occupation and his pecuniary means admit the 
probability that he will take the requisite care of 
himself. For instance, to the well-to-do merchant 
or professional man an occasional attack of ca- 
tarrh or bronchitis may not necessarily excite appre- 
hension, while the same ailments occurring in a 
person whose occupation constantly furnishes the 
exciting cause of such attacks, wall suggest the pos- 
sibility of more serious trouble eventually. 

While the question of occupation, aside from the 
exceptions already mentioned, may usually be left 

20 



GENERAL CONSIDERATIONS. 

to the decision of the home office, the examiner 
ought to have a general idea of the treatment of 
this subject by the different companies. Clergy- 
men, lawyers, schoolmasters, and physicians make 
the best risks according to the order in which they 
are mentioned. Physicians are decidedly the poor- 
est of the four on account of the demands upon 
their strength, irregular hours, and the liability to 
drug^ habits. Everything else being equal, outdoor 
labor is more healthy than indoor. Statistics make it 
clear that those engaged in agriculture head the scale 
in life value. Even seamen, though subjected to all 
kinds of exposure and vicissitudes of temperature, 
are remarkable for their high state of health. The 
evils of dusty trades are materially less'ened when 
they are pursued in the open air or under sheds 
only partially closed. The occupation hazard may 
be classified into three groups : 

1. The risk from increased liability to accident. 
Many of the iron and tin workers, coal miners, 
railway laborers, engineers, firemen, workers in 
electricity, fishermen, seamen, saw-mill operators, 
etc., are in this class. 

2. The hazard on account of the diseases which 
may be occasioned. Stone cutters, copper and lead 
miners, grinders, file makers, lead, brass and cop- 
per workers, potters, glass makers, plumbers, 
painters, etc., are included in this group. 

3. Occupations requiring the handling of alcohol- 
ics. In this class the majority of workers consume 
a large and constant quantity of alcohol and mater- 
ially shorten their lives. 

It is sometimes remarked that human life is the 
cheapest thing on earth. While this may still hold 
true to some extent, a great improvement in the 
conditions affecting workers has gradually come 
about through legislation, sanitary laws, political 
and educational privileges, and advance in wages. 
Mechanical devices have been adopted which mate- 
rially reduce the risks incurred by employees, such 
as air brakes, automatic couplers, blowers for car- 

21 



INSURANCE MEDICINE. 

rying off dust and gases, and various mechanical 
contrivances for doing parts of work formerly done 
by hand. Laws and sanitary measures will not, 
however, remedy all the evils arising from un- 
healthy occupations for reasons for which the work- 
ing people themselves are responsible. Notwith- 
standing the efforts of some lawmakers to fasten all 
the liability and cost of damages upon employers, 
thereby ignoring the factor of contributory negli- 
gence, it requires no lengthened acquaintance with 
workmen to discern their recklessness, gross care- 
lessness, frequent neglect of cleanliness, failure to 
make the most of preventive measures against evi- 
dent dangers, and, above all, the too widespread 
habit of intemperance. 



22 



Chapter II. 

PERSONAL HISTORY. 

General Remarks. — It is the plain duty of every 
one employed by a life insurance company to assist 
in the conservation of the interests of its policy 
holders. The idea that a life insurance company is 
simply an immense money-making corporation run 
for the benefit of a comparatively few stockholders 
is fallacious as regards most companies, bat is so 
prevalent that when a company finds it imperative 
to appeal to a court of justice it is difficult to find 
an impartial, unprejudiced jury. A life insurance 
company does exist to save money to a legitimate 
degree for its policy holders, however, and it would 
indeed be unreliable and unworthy of the name if 
its business w^ere not conducted on an economic and 
conservative basis with that end in view. Among 
other things, a mortality higher than the normal 
will cut into dividends to which the policy holders 
and their beneficiaries are entitled. In order to 
avoid this contingency there must be a proper se- 
lection of lives w^hose chances of attaining the full 
limit of longevity are not impaired by present or 
past disease or injury, or by the results of bad 
habits. 

In securing this personal history the medical ex- 
aminer is not expected to have the scope of his in- 
quiries limited by the application blank — on the con- 
trary, he is counted upon to get possession of all 
possible information and to clear up doubtful, am- 
biguous, or indefinite answers. Each impairment 
admitted by the applicant should be carefully con- 
sidered in all its aspects and a searching inquiry 

23 



INSURANCE MEDICINE. 

should be made as to the cause, symptoms, recur- 
rences, and all possible complications and after- 
effects. In some cases the cause will be of most 
interest. For instance, an applicant makes a state- 
ment that he had a bilious attack one year ago. Med- 
ical directors have learned from experience that a 
certain proportion of so-called bilious attacks are 
caused by gallstones or appendicitis. Therefore, 
the examiner who merely reports the bilious attack 
and does not indicate that he has made further in- 
quiry and eliminated both conditions in the etiology 
is sure to have a request from the home office to 
supply the missing information. In other disorders 
the important point will be the number and dates of 
each attack, and possible complications and after- 
effects, such as rheumatism and gout. In most ail- 
ments the examiner will have occasion to use his 
best judgment and knowledge of diseases in order 
that he may probe in the right direction for further 
information and make up a complete and compre- 
hensive report. 

The examiner is cautioned against being satisfied 
with general questions. The applicant, however in- 
telligent and honest, will fail to grasp the under- 
lying meaning of many of the general questions 
unless they are dissected and explained to him in 
detail. If he is disposed to conceal facts, general 
questions afford him an excellent opportunity to 
evade the issue. Only recently the writer had occa- 
sion to interview an applicant who had just been 
examined and admitted a visit to a health resort in 
Europe for suspected glycosuria in 1895. He had 
answered the general question ''Have you ever 
been to a health resort," and it had not occurred to 
the examiner to inquire more closely. A few addi- 
tional questions, however, brought out the further 
admission that he had visited the same resort in 
1897 and again in 1899, although even then he tried 
at first to have it understood that he had not gone 
for the treatment of any ailment during the last 
two visits. 

24 



PERSONAL HISTORY. 

The illustration given in the preceding paragraph 
demonstrates how the medical examiner's relation 
to the applicant for life insurance is the reverse of 
that which he occupies in his professional capacity 
as physician, for, while the patient exposes his in- 
firmities and even intensifies them, the applicant for 
life insurance may desire to lessen their importance 
or conceal their existence. 

The unwilling applicant, only partially convinced 
by the agent but persuaded to submit to an exam- 
ination, is not apt to help the examiner by going 
into the particulars of his case, and he will occa- 
sionally be disagreeable enough to make it a diffi- 
cult proposition for the examiner to extract satis- 
factory answers from him. Under such circum- 
stances the examiner will be put on his mettle in 
getting the desired facts and will not succeed with- 
out bringing all his tact and forbearance and, also, 
his persistence into action. In spite of this attitude 
on the part of the applicant the report should be 
made complete, as the agent will usually succeed in 
placing the policy after he has the examination and 
other necessary preliminaries out of his way. 

The applicant with slight regard for veracity, for 
the terms of a contract, and for the spirit in which 
the business of life insurance is conducted is too 
often encountered. He will glibly tell the examiner, 
when some admittance has been extorted from him, 
or when confronted by the fact that he has failed to 
''give all the truth and nothing but the truth," that 
he did not suppose it amounted to anything and was 
not worth mentioning. Or he will remind the ex- 
aminer that he actually deserves praise for admit- 
ting some certain point, as no one would have been 
the wiser if he had not mentioned it. The examiner 
should make it emphatically clear to this applicant 
that the straightforward, honorable way is the only 
safe one to pursue if he wishes to avoid possible 
trouble and inconvenience in the future. 

The importance of truthful, complete, and correct 
answers from the applicant in giving his personal 

25 



INSURANCE MEDICINE. 

history has been dwelt upon for the reason that, 
aside from the fact that they are necessary before a 
decision can be given at the home office, the law 
allows a life insurance company to cancel its policy 
within a reasonable length of time if it is proved 
that the applicant was guilty of misrepresentation 
or false statements in his application. A reputable 
life insurance company is very much averse to 
taking such a step, but the interests of the policy 
holders demand it when palpable fraud is exposed, 
both for the moral effect produced in deterring 
others from attempting this evil practice and to re- 
lieve the company of a responsibility it could not be 
expected to assume. There is never the slightest 
occasion for apprehension in the mind of a policy 
holder, if he has fully answered the questions truth- 
fully and candidly, that his company will not cheer- 
fully meet every obligation. 

In taking up the different subjects under personal 
history in these columns, emphasis will be laid on the 
important points to be covered by the questions. 
An opportunity will be afforded at the same time 
for explaining the bearing of many of the queries 
from the home office which seem to the examiner 
to be irrelevant and uncalled for. 

Nervous System. — The stress in modern meth- 
ods of business and the excesses in certain classes 
of society, especially in the large cities, are causing 
a large and increasing number of cases of diseases 
of the nervous system, some of which are difficult 
to discover in the early stages and are both incura- 
ble and fatal. One of our foremost neurologists has 
made the statement to a medical director of one of 
the companies that he would guarantee to produce 
individuals who would be passed by the majority of 
the best life insurance examiners and yet who 
would die in three or four years. While, then, 
a searching inquiry should be instituted whenever 
the applicant admits the history of a disorder which 
is likely to be associated with some mental derange- 
ment or which is liable to recur or leave a permanent 

26 



PERSONAL HISTORY. 

physical defect, the examiner should also have in 
mind the possibility of the existence of one of these 
dreaded diseases in which the premonitory signs 
are so insidious and obscure. Subjects of marked 
disease of the nervous system, when the diagnosis 
is comparatively easy, rarely apply for insurance 
except in the case of those who have had infantile 
paralysis and been left with some atrophy and diffi- 
culty in locomotion, a condition which does not de- 
tract from the value of a life as a rule. An exam- 
ination for life insurance cannot be considered com- 
plete unless the reflexes are tested, the pupils in- 
spected, and the tongue scrutinized for the presence 
of the fine tremor which indicates alcoholism or the 
onset of general paralysis of the insane- The actual 
inspection of the person of the applicant for the de- 
tection of these troubles will be taken up further on 
under the subject "Physical Examination.'' 

Dizziness, Vertigo, — In reporting, give the date 
and cause of each attack. Most people have had 
some dizziness or vertigo as the result of a gastric 
disturbance, bilious attack, or constipation, and if it 
was undoubtedly due to one of those causes it may 
be considered of little consequence, especially if the 
applicant was under 40 years of age at the time. 
Inquiry should be made, however, as to whether 
there was any loss of consciousness during the at- 
tacks, and, if so, whether there was any suspicion 
of convulsions or one of the mild forms of epi- 
lepsy. When the individual has passed the age 
of 40 dizziness or vertigo should not be regarded 
with complacency, as it may then be an early sign 
of cardiac weakness, vascular changes in the brain, 
or nephritis. 

Unconsciousness, Fainting. — Give the date, dura- 
tion and cause of each attack. It may have been due 
to injury, shock, emotion, or some illness. In the 
absence of any known cause it will be safer to as- 
sume that it was the result of cardiac weakness, 
some vascular cerebral change or epilepsy. 

Epilepsy, — Give the frequency and severity of the 

27 



INSURANCE MEDICINE. 

attacks and the date of last occurrence- A history 
of confirmed epilepsy will cause rejection of the 
applicant even after a long period of immunity from 
attacks, as, in addition to the danger of recurrence, 
there is almost always a physical and mental impair- 
ment. 

Convulsions. — Give the date, severity, and cause 
of each attack. A history of convulsions of infancy 
may be overlooked if there has been no recurrence 
since. Under all other circumstances they must be 
considered a grave manifestation either of some or- 
ganic lesion, as nephritis, or of some neurotic weak- 
ness, such as hysteria, epilepsy, insanity, etc., any 
one of which will justify rejection of the risk. 

Paralysis. — Give the date and cause of the attack 
and the variety of paralysis. A history of Bell's 
paralysis is inconsequential, although it should be 
recorded after a careful inquiry has convinced the 
examiner that the palsy was due to a peripheral 
neuritis and not to a central lesion. Disability, fol- 
lowing an early anterior poliomyelitis, should be 
fully described, as there is no objection to the ac- 
ceptance of such risks provided the locomotion is not 
too much interfered with and the assistance of 
crutches is not required. Local palsies, such as 
''writers' cramp," lead poisoning, traumatic local 
paralysis, etc., may only lead to postponement of 
the application, until the local causes are relieved. 
A history of any paralysis of cerebral origin will 
be regarded seriously and the risk rejected. 

Apoplexy — Any history of cerebral apoplexy 
leads to absolute rejection. When an applicant ad- 
mits dizziness, vertigo, syncope, or unconsciousness, 
the examiner should keep the possibility of apoplexy 
in mind and institute a strict inquiry into the nature 
of the attack. 

Insanity, — Insanity is seldom acknowledged as 
such by the applicant ; he will usually insist that the 
malady was in some other form, such as neuras- 
thenia, nervous prostration or nervous break- 
down. Any history of mental derangement al- 

28 



PERSONAL HISTORY. 

most always indicates a short life, although it is 
true that some of the worst cases of insanity enjoy 
vigorous physical health. Such risks will be re- 
jected. 

Neurastheniaj Nervous Prostration, — Always 
give dates, duration, severity, and cause of each at- 
tack. Whenever there is a history of a nervous 
breakdown or of a resort to treatment for nervous- 
ness, worry, fatigue, etc., there should be a careful 
inquiry as to the exact nature of the attack. This 
history is often elicited from business and profes- 
sional men. The condition known as neurasthenia 
or nervous prostration is often regarded too lightly, 
and an examiner is apt to record the bare statement 
of its occurrence without making further inquiry. 
There is a fairly wide range of possibilities in the 
disorder. It may be defined as a functional disturb- 
ance of the nervous system, characterized by weak- 
ness and irritability, lying between hysteria and in- 
sanity, occasionally overlapped by one or the other 
— more frequently the former, rarely the latter. It 
must be ascertained positively whether the disorder 
was one of "brain-fag" or cardiac irritability, or 
whether it was accompanied by insomnia or some 
form of mental derangement. It should not be for- 
gotten that insomnia is a common symptom of 
neurasthenia and insanity. 

Neuralgia^ Neuritis. — The ordinary neuralgias, 
so commonly met with, need little or no comment. 
The history of sciatica should be given in full, for, 
while it is usually due to a peripheral neuritis which 
disappears witHout leaving any effect on the general 
constitution, it may indicate some trouble in the 
brain or spinal cord in rare cases. With a history 
of neuritis the examiner should bear in mind that 
this condition is often the result of alcoholism and 
that careful questioning, therefore, is necessary. 

Delirium Tremens, — Give frequency of occur- 
rence and date of last attack, and state whether ap- 
plicant resorted to a "cure," and has been a total 

29 



INSURANCE MEDICINE. 

abstainer since the last attack and also since taking 
the cure. 

Tremor. — The presence of a tremor should lead 
to a careful inquiry as to the cause. It may be con- 
genital and of no great importance, it may occur in 
nervous people excited by passing causes, it may 
be due to the nervousness of illiteracy, or it may be 
a symptom of ''writers' cramp.'' On the other hand 
it may result from alcoholic excesses, paralysis 
agitans, or disseminated sclerosis. 

Headaches. — The ordinary headaches are not 
worth mentioning unless they have been severe, pro- 
tracted, or frequent. If they are reported the exam- 
iner should give fiill particulars as to frequency, 
severity, duration, and cause, and he should state 
specially whether they are due to gastrointestinal 
disturbances, eye-strain, migraine, overwork, etc., 
or whether they are due to some more serious or- 
ganic lesion or functional disturbance. 

Sunstroke. — Give date and full details of any 
sequel such as epilepsy, headache, and inability to 
work in the sun. The acceptance of such risks is 
not advisable until they have gone through at least 
one more summer without feeling any effects of the 
sun or heat. 

Circulatory System. — The personal history in 
regard to diseases of the circulatory system is usual- 
ly meager for the reason that an applicant who un- 
derstands that he has a heart murmur or diseased 
arteries is not likely to apply to a company that 
does not issue substandard policies. The majority 
of applicants in whom these conditions are dis- 
covered at the examination learn of them then 
for the first time. Occasionally, however, some 
person will apply who has previously been rejected 
and has learned that this action was taken on ac- 
count of a heart murmur. He may admit this and 
at the same time declare that he has been examined 
since by his attending physician or some other 
doctor and found free from any indications of 
heart disease. He naturally believes in the more 

30 



PERSONAL HISTORY. 

favorable diagnosis and, for this reason, feels justi- 
fied sometimes in omitting the statement that any 
trouble was ever found with his heart. It is a 
good idea to question every applicant closely as to 
whether he has ever been refused the kind of in- 
surance he applied for and, if he has, to ascertain 
the cause when possible. If he admits it was heart 
trouble or does not know, the heart should be ex- 
amined even more carefully than usual during rest 
and also after he has been put through some form 
of exercise. 

While, then, the previous history of defects in 
the circulatory system will not prove important in 
most cases and reliance for discovery of them must 
be largely based upon the physical examination, it 
is essential to question the applicant in regard to 
the following conditions: 

Palpitation, Irregularity, Intermittency, — Ascer- 
tain the date, duration, and cause of each attack. 
Whenever an applicant acknowledges a history of 
one or the other of these disturbances, the heart 
should be thoroughly examined both during rest 
and immediately after some form of exercise to* 
determine its size and location and whether there 
is a murmur. 

Experience has convinced many physicians inter- 
ested in life insurance that a persistently irregular 
or intermittent heart action does not detract from 
the insurability of a risk when the applicant is 
under 40 years of age, has not indulged in the 
excessive use of alcohol, is not an overweight, and 
all heart lesions have been excluded after a careful 
reexamination. Moreover, a heart action slightly 
over 90, the maximum rate commonly adopted by 
the companies, is not seriously considered in one 
who also is within the normal limits of weight, 
under 40 years of age, and has not used too much 
alcohol ; but in these cases a careful reexamination 
of all the organs is required in order that the ex- 
aminer may assure the company that the rapidity 
is not excited by some pathological condition. A 

31 



INSURANCE MEDICINE. 

full history in both these classes of cases should 
be always furnished, even though no abnormality 
is discovered in the examination. When no focus 
of irritation is found to account for the irregular, 
intermittent, or rapid heart action in these appli- 
cants, it may be set down as an idosyncrasy, prob- 
ably the overflow of a rather active nervous sys- 
tem. If it is learned after a searching inquiry that 
the disturbance of the heart action was transitory 
and undoubtedly due to some unusual exercise, the 
fact is not worth recording. 

Dyspnea, — A history of difficulty in breathing 
due to pulmonary congestion is sometimes obtained 
when the applicant has been subject to heart dis- 
ease. The chief importance of the symptom will 
be to emphasize the gravity of the disease, as a 
lesion extensive enough to cause this disturbance 
will be easily recognized during the physical ex- 
amination. 

Pain in Region of Heart. — Give date, duration, 
severity, and cause of each attack. Close question- 
ing will bring out the fact that the pain was caused 
by intercostal neuralgia in many of the cases, but 
the examiner is reminded that intercostal neuralgia 
is often given as the origin of pain in the chest 
when the real cause was pleurisy or angina pectoris. 

Acute Rheumatism, — Whenever a history of this 
disease is obtained the examiner should endeavor 
to learn whether there was any form of involve- 
ment of the heart during or immediately after the 
attack. The date of the attack of rheumatism, the 
nature of the cardiac trouble, and the date of its 
last manifestation will be required. 

Dropsy. — Ascertain the date, duration, cause, and 
parts affected. The dropsy may have followed ma- 
laria, some fever, or acute disease of one of the 
organs, in which case the risk will usually be ac- 
ceptable if sufficient time has elapsed since full re- 
covery. If, however, it occurred as a result of some 
form of heart disease the risk will not be accepted. 

Purpura Hemorrhagia. — A history of this condi- 

32 



PERSONAL HISTORY. 

tion is always ground for rejection, as it is liable 
to be accompanied sooner or later by dangerous 
internal hemorrhages as well as effusions of blood 
under the mucous membranes. It is highly im- 
portant to learn whether the applicant is a "bleeder, 
when he gives a history of nose bleeding, prolonged 
bleeding after extraction of teeth, or bleeding from 
the gums. 

Anemia. — Ascertain the date, duration, and 
cause. In most of the cases it will have been due 
to some passing cause w^hich does not detract from 
the value of the risk after full recovery. On 
the other hand, an investigation may bring out the 
fact that it was due to a chronic constitutional dis- 
ease such as nephritis, pulmonary tuberculosis, or 
syphilis. 

Varicose Veins. — An applicant with extensive 
varicose veins should be rejected. When the vari- 
cosities have not recently progressed rapidly, are 
not too marked or extensive, and are helped by 
the use of an elastic stocking, they may be ac- 
cepted provided the history is one in which the 
occurrence of large or frequent ulcerations does 
not enter. 

Respiratory System. — The examiner cannot be 
urged too strongly to question the applicant closely 
and definitely in regard to any affection of the 
respiratory tract admitted by him, whether trivial 
or severe, since so large a proportion of deaths in 
adult life are brought about by these diseases. Prob- 
ably, in this class of cases more than any other 
the examiner will experience difficulty at times in 
getting an accurate history, owing to the well- 
known reluctance of the average man to acknowl- 
edge or even believe that there was any suspicion 
of tuberculosis during some certain disturbance 
in his lungs or that there might be any liability to 
the development of this condition later on as a re- 
sult of the attack in question. 

Chronic or Persistent Cough, or Hoarseness. — 
Ascertain the date, duration, severity, and cause of 

33 



INSURANCE MEDICINE. 

each attack. Always ask specifically as to whether 
there was any suspicion of tuberculosis or spitting 
of blood. The applicant cannot be relied upon to 
help the examiner in this even if he is inclined to 
be honest, as an individual w^ho has suffered from 
a pulmonary complaint often has a propensity to 
view his case in a too favorable light, a propensity 
so strong, in fact, that he may not deem it worth 
while to mention it to the examiner. When a 
cough or hoarseness lasting some length of time 
is acknowledged, the examiner is depended upon 
to question the applicant very closely, as well as to 
make an extra careful examination, in order to 
discover the cause and nature of the illness and 
assure himself that the disturbance was due to 
simple nasal catarrh, to an ordinary congestion of 
the fauces and pharynx with excess of mucus, to 
granulations in the vault of the pharynx which 
get dry and cause irritation, to a long uvula, or to a 
nervous or sympathetic influence, conditions com- 
mon in America and of little consequence unless 
severe; or, on the other hand, as to w^hether the 
habitual cough or hoarseness was excited by some 
more serious involvement of the air passages. The 
applicant should be asked to describe the form of 
treatment followed at the time and also whether 
he resorted to a change of climate for a cure. 

Spitting or Coughing of Blood. — Ascertain the 
exact date of each attack and the source of the 
hemorrhage. Every case of blood spitting should 
invariably be reported, no matter what the alleged 
source may be or how far the applicant is con- 
vinced that it was of no consequence. The ex- 
aminer should remember that nearly every individ- 
ual who has raised some blood is ready to explain 
that it came from the nose, gums, or "throat," 
from anywhere, in fact, but the lungs. The pre- 
sumption, however, is always that the hemorrhage 
originated in the lungs, thereby giving the com- 
pany the benefit of the doubt. 

We have to admit, nevertheless, that blood may 

34 



PERSONAL HISTORY. 

come from the lungs when there is no tuberculosis 
present, as a result of traumatism or some violent 
effort, but an hemoptysis should not be looked upon 
as accidental unless distinctly coincident with some 
injury inflicted or some violent physical exertion 
made at the time, and it should also be borne in 
mind that, even if it did occur with unusual exer- 
cise, tiie hemoptysis may have been caused by the 
breaking down of tissues weakened by disease and 
which would have withstood the shock if they had 
been in a healthy condition. 

Again, there are cases in which the hemoptysis 
was an early symptom of tuberculosis, but the at- 
tack proved abortive and the applicant apparently 
recovered, the process of recovery consisting in an 
encapsulation of the diseased tissue, which, as is 
usual in such instances, contains tubercle bacilli, 
and the condition should, therefore, be termed one 
of latency rather than of recovery. The danger of 
autoinfection in such a patient is so great that the 
risk will not be insurable until many years have 
elapsed if at all. 

If there is a history of the typical rusty sputum 
of pneumonia, the full details will be wanted at the 
home office, especially the duration of the attack 
and the nature of any complications, so that tuber- 
culosis can be positively excluded. 

The practice usually observed in acting on cases 
of blood spitting is to accept them after a period 
of about ten years has elapsed since the attack, pro- 
vided that there was no suspicion of tuberculosis, 
that the applicant has not been subject to other 
disturbances in the respiratory tract, and that the 
physique and family history are satisfactory. This 
action is based upon the assumption that the hemor- 
rhage was accidental or from some source outside 
of the lungs, and that ample time has been allowed 
for any tuberculosis present in the beginning to 
assert itself. Among the cases acted upon in this 
way there will possibly be an occasional one of 
the doubtful variety already referred to, in which 

35 



INSURANCE MEDICINE. 

the preliminary attack of tuberculosis aborted, 
leaving only a small scar extremely difficult or 
even impossible to discover in the physical exami- 
nation. 

Bronchitis. — Ascertain the number of attacks 
with the date, duration, and severity of each one, 
and investigate carefully as to whether there was 
any hemoptysis or suspicion of tuberculosis. If 
it is certain that the attack was due to an ordinary 
cold, it may be considered unimportant unless other 
attacks have occurred. Frequently recurring bron- 
chitis, even if not complicated by tuberculosis, nat- 
urally impairs the expectation of life and will usu- 
ally afford grounds for postponement or rejection. 

Pneumonia. — Give the date, duration, and com- 
plications of each attack. It is not a good practice 
to accept these risks unless from six to twelve 
months have elapsed since the attack, and the ap- 
plicant has fully regained his fomier weight and 
health and has not suffered from serious complica- 
tions or other recent attacks. The length of the 
period of postponement will depend largely upon 
the season of the year. If winter is coming on it 
is wiser to delay the acceptance of the risk until 
the following spring, but if the applicant has the 
summer immediately before him he may be safely 
insured in six months after the pneumonia, every- 
thing else being favorable. 

Pleurisy. — The approving officers at the home 
office will not be in a position to act finally on a 
case in which there is a history of pleurisy until 
the date, duration, and severity of the attack are 
known, what form it assumed and whether there 
was any suspicion of tuberculosis. It cannot be 
contested that the tubercular nature in a large per- 
centage of the cases of pleural effusion and even 
dry pleurisy has been established, and that pleurisy 
may sometimes be the first expression of tubercu- 
losis. If the exudate was purulent the problem 
usually to be considered is the amount of impair- 
ment of the lung from collapse with the subse- 

36 



PERSONAL HISTORY. 

quent lowering of the vitality of the individual. 
The permanent damage to the lung and the con- 
sequent falling of the chest wall are apt to be more 
pronounced and bronchial affections are more com- 
mon in after life, if the empyema occurred after the 
age of twenty. 

The examiner should be suspicious when a his- 
tory of pleurodynia or intercostal neuralgia is ad- 
mitted, as in many of these cases the real disease 
was pleurisy, dry or with a small effusion. The 
writer has just had occasion to review a death 
claim in which it appears that the attending 
physician at first attributed the symptoms to inter- 
costal neuralgia; soon, however, he changed his 
diagnosis to one of pleurisy and the patient died 
at the end of eighteen months from pulmonary 
tuberculosis. 

Consumption, — A history of pulmonary tuber- 
culosis will always lead to rejection even if the 
applicant has fully recovered. 

Asthma. — Give the frequency, duration, cause, 
and severity of the attacks, and the date of the last 
attack. Also ascertain whether the spasms are 
growing milder and less frequent. If it occurs 
only during attacks of hay fever this fact should 
be reported, as the disorder is not seriously con- 
sidered in such cases. All these data are necessary 
before intelligent action can be taken at the home 
office. 

Dyspnea. — The applicant should always be asked 
if he has had any shortness of breath and, if so, the 
date and circumstances under which it took place. 
The causes are so numerous and well known that 
the enumeration of them is not necessary. 

The Digestive System. — In this class of dis- 
eases, more than any other probably, there are con- 
ditions in which difficulty in diagnosis is frequently 
encountered and in which grave and menacing dis- 
orders may be associated with and masked by 
symptoms pointing apparently to comparatively un- 
important ailments. At the time of the exam- 

37 



INSURANCE MEDICINE. 

ination all signs of these disturbances may have 
departed, and yet the primary trouble may re- 
main dormant or is liable to recur. With these 
possibilities in mind, even though the exam- 
iner has gathered all the history obtainable and 
reports a negative result from his examination, a 
medical director will often find it necessary to ask 
the applicant to furnish a certificate from the phys- 
ician who attended him during the illness and who 
is therefore the only one in a position to give a 
well-defined idea of the real nature of the trouble. 
After all these precautions have been observed, so 
much doubt may still remain that the applicant will 
be postponed or rejected in order that the company 
may be given the benefit of the doubt. 

Dyspepsia, Indigestion, Biliousness. — Ascertain 
the frequency, duration and cause, and the date of 
the last attack. These disturbances, so common in 
America, are not usually regarded as worthy of 
much comment, and in m^ost cases this attitude is 
justified. When, however, the attacks come fre- 
quently or the condition is more or less chronic, 
they should be looked upon as an important factor 
in the selection of risks, especially if the weight of 
the applicant is under the standard or there is a 
poor family history. Dyspepsia or indigestion may 
be an early symptom in tuberculosis or various 
organic diseases, but the chief point of interest, 
probably, is whether or not the attacks are indi- 
cations of or associated with appendicitis or affec- 
tions of the gall bladder. 

Given, then, a history of dyspepsia, indigestion, 
or biliousness, the examiner should use his best 
efiforts in trying to find out whether the trouble 
was primary or whether it was secondary to one of 
the more serious maladies. The medical staff at 
the home office will often want a certificate from 
the attending physician in cases of fairly recent 
disorders of the digestive system in order that 
gall stones and appendicitis may be eliminated as 
far as possible. 

38 



PERSONAL HISTORY. 

Hematemesis. — Give the number of times the 
applicant vomited blood and the date of each oc- 
currence. The conditions which cause hematemesis 
are so serious and apt to recur, even after recovery 
has apparently taken place, that a long period should 
elapse before such a risk will be accepted. 

Diarrhea. — Report the date, duration, frequency, 
and cause if the attack was a prolonged one or 
if there were several of them. 

Appendicitis. — Give the date and duration of 
each attack, and the date of the last attack. If 
there has been an operation, ascertain the date, 
whether the appendix was removed, whether there 
was pus, whether there were adhesions and, if so, 
how extensive, and whether there was healing by 
first intention. 

When there have been one or more well-defined 
attacks it is easy to get a true history, but un- 
fortunately many of the cases develop insidiously 
and without the typical signs. A number of cases 
occur to the writer as illustrations, but the follow- 
ing instances will be sufficient to emphasize the 
point : 

1. A physician was affected, as it seemed to him 
and his medical friends, with severe intestinal in- 
digestion and fermentation for about a year, the 
malady refusing to yield to remedies and out-of- 
door life. At the end of the year the trouble re- 
solved itself into a fairly typical attack of appen- 
dicitis. The appendix when removed gave evi- 
dence of an inflammatory condition of long stand- 
ing and the intestinal indigestion began to depart 
on recovery from the operation. 

2. Another interesting case which came under 
the writer's observation and caused considerable 
comment at the time is that of a young man with 
a history of typhoid fever one year previous to 
his application for insurance. The typhoid was 
followed by mild attacks of intestinal cramps of 
an hour's duration about once a month. The phys- 
icians, men of reputation, believed that the cramps 

39 



INSURANCE MEDICINE. 

were caused by an irritable colon as a sequel to the 
typhoid fever. Two years after the supposed 
typhoid an operation revealed the presence of 
chronic appendicitis with extensive adhesions. The 
patient was relieved of his disagreeable symptoms 
by the operation. 

3. This case is one of common occurrence. The 
applicant admitted in an examination in August, 
191 1, that he had some biliousness in the previous 
year. A certificate from the attending physician 
was asked for and from this it was learned that the 
so-called biliousness consisted of two attacks of 
mild catarrhal appendicitis with some colic. 

The subject of appendicitis has been treated at 
some length on account of the atypical courses 
followed by the disease and the high mortality ex- 
perienced as a result of it, notwithstanding the per- 
fected technique of abdominal surgery. The exam- 
iner cannot be too searching in his questions and 
examination whenever the applicant admits gastric 
or intestinal pains or any other symptom, no matter 
how mild, pointing to trouble in the gastrointes- 
tinal tract. 

Colic. — Recurrent attacks of abdominal pain or 
even one attack when recent should suggest ap- 
pendicitis, gall stones, renal colic or plumbism, 
and lead the examiner to be very inquisitive in 
eliciting the personal history with this probability 
in mind. Full details as to dates, duration, severity 
and cause, as well as the date of the last attack will 
be required. 

Disease of the Liver. — Aside from cancer and 
cirrhosis, the serious forms of liver troubles are 
seldom met in this country. A history of gastro- 
enteritis, the so-called bilious attack, is unimpor- 
tant unless it was severe, protracted or recurrent, 
and its association with some condition of a graver 
nature cannot be excluded. 

Jaundice. — Ascertain the dates, frequency, dura- 
tion, severity and cause; also whether there were 
other symptoms such as pain or tenderness. The 

40 



PERSONAL HISTORY. 

examiner should never regard these cases Hghtly, 
as too frequently when it was assumed that the 
jaundice was due to a catarrhal condition it was 
found later that gall stones were the real cause. 
The failure to find the calculi in the stools is by 
no means positive proof that they were not at the 
bottom of the trouble, as it is such a simple matter 
for them to escape discovery. 

When the jaundice was due to malaria this 
should be reported, as it usually affords evidence of 
a type more severe than the ordinary. 

Gallstones. — Gallstones are a source of con- 
stant danger as long as they remain in the gall- 
bladder or common duct. To make matters worse, 
it is not always easy to determine whether they are 
present or not. Physicians familiar with the work 
in any of the large hospitals recognize the falli- 
bility of even the best diagnosticians through the 
unexpected revelations of the surgeon's knife at 
times, and affections of the gall bladder and ducts 
are probably responsible for as great a number of 
errors as those of any other organ in the abdominal 
cavity. How difficult, then, will it be to discover 
the underlying cause in some cases in which the 
indications, merely some passing pain, digestive 
disturbance, slight tenderness apt to escape notice, 
or a little jaundice, were too indefinite and vague to 
occasion more than a casual visit to the attending 
physician. And yet in these cases, as well as in 
those with well-pronounced symptoms, the stones 
are a menace to life as long as they remain. In 
consideration of the facts presented, the examiner 
should be unusually persistent and careful in get- 
ting at the full history of any one of the symptoms, 
however mild and vague, which may have indicated 
the presence of hepatic calculi. 

In operative cases, it will be necessary to have 
the applicant procure a statement from the sur- 
geon as to the part involved. It seems to make but 
little difference from a life insurance point of view 
whether the gall bladder was drained or removed. 

41 



INSURANCE MEDICINE. 

When, however, the common duct was involved 
in the incision, the case is looked upon as more 
serious and as one in the later stage of gall-stone 
disease with dilated ducts into which the stones may 
slip out of sight, with denser adhesions to sur- 
rounding structures and with a greater liability to 
malignancy or other serious complications. 

The best way to treat these cases at the home 
office is to refuse to issue insurance when no oper- 
ation has been performed until at least five years 
have elapsed since the attack. If there have been sev- 
eral attacks it may be wiser to lengthen the period. 
The risk may be assumed after a shorter period 
when there has been an operation for drainage or re- 
moval of the gall-bladder, but a much longer time 
should elapse when the common duct was invaded. 

Hemorrhoids. — These will require no comment, 
whether external or internal, unless considerable 
blood is lost. When the applicant has had an oper- 
ation performed at an age of forty or older, he 
may be required to furnish a certificate from his 
attending physician as to whether or not there 
was any suspicion of malignancy. 

Fistula. — It must always be definitely settled 
whether there was any suspicion of tuberculosis. 
The date and duration should be given. 

Tapeworm. — Ascertain if the head passed away 
at the time of removal. If the head was not found, 
it is better to wait a few months before accepting 
the risk. 

The Genito-Urinary System. — Degenerative 
changes in the kidneys are responsible for a mor- 
tality which is exceeded only by that due to path- 
ological conditions of the blood vessels and heart, 
both of these classes of diseases having su- 
perseded tuberculosis, which at one time occupied 
first place in the list. It may be added that this re- 
versal has been brought about less by the extermina- 
tion of tuberculosis than by an increase in the death 
rate due to degenerative changes occasioned by the 
greater stress of modern business methods, by the 

42 



PERSONAL HISTORY. 

extension of social pleasures into the late hours 
when physical and mental rest are so much needed 
and by the excessive eating and drinking which so 
often accompanies the accession of financial means. 

It is highly important, then, for the examiner to 
cross question the applicant closely whenever there 
is a history qf one or more of those conditions 
which, though not necessarily fatal in themselves, 
may provoke the permanent and dangerous changes 
to which the tissues of the kidneys are particularly 
susceptible on account of the present mode of living. 

Diseases of the Kidneys — A history of the chronic 
affections of these organs will rarely be elicited 
from an applicant for life insurance. A previous 
occurrence of acute Bright' s disease is, however, 
admitted at times and will lead to postponement un- 
til it is certain that a return of the trouble will not 
take place and all after effects have disappeared. A 
careful examination of the urine will be resorted to 
before final acceptance of the risk. 

Albuminuria — When there is a history of albu- 
minuria, even though there were no indications of 
involvement of the kidneys, the examiner will be 
expected to make an urinalysis of several specimens 
voided on different days and at different hours, 
preferably the morning, noon and evening urine of 
these days. It is advisable to have the applicant 
sign a statement that he has not been under treat- 
ment or on restricted diet for this disorder for at 
least six months. If these measures are not adopt- 
ed, permanent or frequent recurring albuminuria 
cannot be excluded. 

Movable Kidney — When there is a history of 
sickening or dragging pains in the abdomen, espe- 
cially in women, the possibility of the presence of a 
floating kidney should be borne in mind. These 
cases are not acceptable unless the kidneys have 
been successfully fixed and time enough has elapsed 
to discover if the organs will remain in place. 

Renal Colic — Give the number of attacks and the 
date of the last one, and ascertain if gravel or a 

43 



INSURANCE MEDICINE. 

stone passed from the urethra at the time. The 
term gravel should not be used to describe the pre- 
cipitation of urates and uric acid sometimes occur- 
ring after the urine has become cool and which is 
of no importance even though it has often been the 
chief support for a diagnosis of ''uric acid diathe- 
sis/' The examiner will usually be requested to 
send a specimen of urine to the home office for 
microscopical examination, as the presence of red 
and white blood cells is occasionally demonstrated 
for a long time after an attack of renal colic, a pos- 
sible indication that some damage to the tissues still 
exists or another stone is present. 

The general opinion in regard to these cases is 
that they may be accepted when at least six months 
have elapsed since the last attack, provided there 
have not been too many recurrences and the mi- 
croscopical examination of the urine is satisfactory. 
This view is apt to be modified, however, if the ap- 
plicant is over forty years of age or an overweight, 
as in either event a longer period of postponement 
is advisable. 

Hematuria — Give the dates, number of attacks 
and cause, and state whether there was accompany- 
ing pain, colic or passage of a renal calculus. It 
should be also made plain whether the blood ap- 
peared in the urine during an attack of malaria, 
as this condition is still common in some parts of 
the country. 

Pelvis of the Kidney, Ureter, Bladder — Purulent 
inflammation of these parts is apt to travel up into 
the kidneys, and an inquiry should be instituted with 
this possibility in mind whenever there is a history 
of such a condition. 

Prostate Gland— A good many death claims are 
paid where the kidneys have become involved 
through the disturbances set up by enlarged pros- 
tates. Hypertrophy of the prostate to a limited 
extent may exist for a long time without producing 
marked symptoms, and for this reason the condi- 
tion rarely comes to the notice of the physician un- 

44 



PERSONAL HISTORY. 

til it has reached a more or less advanced stage. 
The examiner may well bear this fact in mind when 
the applicant is over fifty years of age. 

Stricture of the Urethra — Complete information 
should be furnished when there is a history of 
urethral stricture, especially as to whether there 
has been any indication of involvement of the kid- 
neys. When sounds have been used, the date of 
cure should be mentioned as well as the size of the 
largest sound which the urethra would admit. In 
mentioning the size of the sound, state whether the 
French, American or English scale is referred to. 

Always question the applicant as to whether he 
has had any frequent or difficult urination and, if 
there is any such history, endeavor to find out if it 
was caused by organic changes in the urethra, pros- 
tate, or kidneys. 

Hydrocele — When there is a history of this con- 
dition it should be included in the report. Give 
dates of all tappings or operations and of any re- 
currence. 

Unclassified Diseases. — Certain disorders 
which are treated in regularly defined groups in the 
textbooks may be considered under the head of 
"Unclassified Diseases in Insurance Medicine'' as a 
matter of convenience. 

Malaria. — The severe forms of malaria are sel- 
dom encountered in the northern part of the United 
States, though a few sporadic cases appear and run 
a typical course in certain localities, but they prac- 
tically never terminate fatally. In the South and 
Southwest, however, malaria of all types is so 
prevalent, even the dangerous forms occurring too 
often, that the people living there have become 
accustomed and indifferent to it and consequently 
inclined at times to ignore it when questioned by 
the examiner. The visitor in the South is often 
assured that everyone has some malaria, but that it 
is of no importance and does not shorten life. 
Nevertheless one has only to go through the hos- 
pitals in the larger cities of the South for an oppor- 

45 



INSURANCE MEDICINE. 

tunity to study aggravated cases of malaria. More- 
over, a fair proportion of death claims is presented 
at the home office in which malaria is given as 
the cause of death. 

There are sections of the South and Southwest 
where malaria with hematuria is common, and in 
some spots the attacks are so pernicious and dan- 
gerous, the writer has been assured by local phys- 
icians of unquestioned authority, that the white 
people have had to keep out. Some years ago the 
writer had a large and interesting correspondence 
on this subject with representative physicians 
throughout the South and Southwest. The answers 
to certain interrogatories were complete and almost 
unanimous, to the effect that fatal cases, specially 
those associated with hematuria, coma, or both, still 
occur, but it was also explained that the diagnoses 
were faulty at times and that the real trouble in 
some instances was either incipient phthisis, gall- 
stones, typhoid fever, intestinal autointoxication, 
appendicitis, or some other trouble. It was the opin- 
ion of the various writers that blood tests were 
seldom resorted to and that the erroneous diagnoses 
were entirely based on the clinical aspects of the 
cases. 

There is no doubt that the violent and pernicious 
forms of malaria in the South are decidedly less 
frequent than in former years and that a great 
change has been brought about by the clearing of 
forests, drainage of swamps, the use of artesian 
wells and screening. But it must be remembered 
that men, while they will clear off the land and 
drain it for agricultural purposes, are apt to neglect 
their health and let up on the eternal vigilance 
which is required to prevent the entrance and 
propagation of the malaria-bearing mosquito by 
properly screening the houses and all vessels hold- 
ing water. 

The question of malaria has been dwelt on, as 
it is an important one not merely from its death- 
dealing qualities directly, but also because of its 

46 



PERSONAL HISTORY. 

power to lower the general tone of the patients and 
render them less able to withstand the attacks of 
other diseases. As stated in the preceding lines, 
many individuals who have lived all their lives in 
malarious districts, have become as accustomed to 
its presence as to the air they breathe and hon- 
estly forget to acknowledge that they are or have 
been victims to the disease. While, then, it is 
undoubtedly true that deadly malaria of twenty 
or thirty years ago has become very much m.odi- 
fied, it is important to get a full history of the 
disease, especially as to the number, dates, dur- 
ation, and frequently of the attacks. The examiner 
should also always ascertain if there was any 
hematuria and, if so, whether the applicant still 
lives in the same locality where he originally con- 
tracted the illness ; furthermore, whether the 
malaria was of the intermittent or remittent type, 
as the final decision at the home office in regard 
to the issuance of the policy will be largely in- 
fluenced by these facts. 

Infectious Fevers. — When there is a history of 
any acute infectious fever always ascertain the 
date and duration and whether there were any com- 
plications or after effects. Also state whether the 
applicant has fully recovered his former weight 
and health. In measles it is desirable to know if 
any pulmonary complaint followed. In scarlet 
fever the officials at the home office wall want to 
know if there were any renal complications and 
will probably require a sample of urine sent to 
them for microscopical examination in recent 
cases. 

Rheumatism. — When there is a history of acute 
articular rheumatism, it is most important, on ac- 
count of the well-known tendency of this disease to 
recur under ordinary exciting conditions and to 
affect the heart, for the examiner to be careful in 
giving the number of attacks, the date, duration, 
and severity of each attack, the name of the joints 
involved, and a full account of any cardiac com- 

47 



INSURANCE MEDICINE. 

plications. The consideration of these facts fairly 
well establishes the individual tendency to recur- 
rence and liability to future trouble, and as appli- 
cants who have had acute inflammatory rheuma- 
tism are classified into those to whom insurance 
may be issued at the ordinary rates or on some 
form of endowment, or who should be postponed or 
declined, no conclusion can be reached at the home 
office until these data are supplied. 

It should always be kept in mind that the heart 
may have been involved during an attack without 
leaving much or any evidence, and a special effort 
should be made to find out if any cardiac compli- 
cation did occur^ as the applicant in s'uch cases is 
not acceptable until at least five years have elapsed 
since the attack. 

The sequelae of acute articular rheumatism 
which tend to shorten life usually show the signs 
of their sinister work when the subject has passed 
the age of fifty, and an endowment policy may be 
written therefore in some cases when it would 
not be advisable to issue one at ordinary rates and 
the case is not bad enough for postponement. The 
most general practice, perhaps, in rating these 
cases is to give a policy at ordinary rates where 
there has been one attack not too recently and an 
endowment policy when there have been two at- 
tacks, the last one at least a year before the date 
of the application. Three attacks indicate so strong 
a predisposition to recurrence that it is advisable to 
reject unless a long period of time has elapsed 
since the last one. 

The endowment policy will be referred to several 
times in these lines when discussing rheumatism, 
gout, syphilis and overweights, and it will not be out 
of the way to give a brief explanation of the value 
of this contract under certain circumstances. The 
evil effects of the conditions just named usually 
begin when the subjects have passed the age of 
fifty or sixty, as the case may be — in other words, 
as a class these applicants do not live up to the regu- 

48 



PERSONAL HISTORY. 

lar expectancy. If, then, a policy can be written 
which will completely mature at about a certain age 
and not call for any further obligations on the part 
of the company, applicants may be accepted on 
this plan who would otherwise have to be rejected. 
The endowment policy fulfills this requirement, 
for by the terms of this contract the transaction is 
absolutely completed at the end of a stated num- 
ber of years on terms fully understood by and satis- 
factory to both the policy-holder and the company. 
It is the termination of the contract at a given age 
rather than the increased premium which makes 
this form of policy so appropriate for certain 
cases. 

Chronic rheumatism develops more commonly in 
adult life and a reliable history is therefore more 
easily obtained, and in addition to this there is apt 
to be some indication of the disorder at the time of 
examination. Patients do have respites from the 
effects of this disease, however, or they may have 
only some remaining pain or stiffness which has 
not affected the general health. In any event a 
complete history should be furnished, as appli- 
cants who are or have been afflicted with this 
trouble, if insurable at all, are only entitled to some 
form of endowment policy. 

An occasional twinge in a joint without any 
previous swelling, inflammation or actual severe 
pain in the part is not worth mentioning. 

Muscular rheumatism or lumbago is of no im- 
portance unless it has become chronic, in which 
case declination or an endowment policy is in order. 
A history of muscular rheumatism or lumbago 
should always be reported and it should be specifi- 
cally stated whether or not any joints were affected 
in order to avoid confusion at the home office. 

Gout. — Rejection is called for in a high percent- 
age of the cases in which there is a history of gout. 
Before intelligent action can be taken at the home 
office, full details will be required, especially as to 
the number of attacks, the date, duration and 

49 



INSURANCE MEDICINE. 

severity of each attack and the names of the joints 
affected. Furthermore, the medical officers will 
want to be informed whether there have been any 
gouty symptoms between the acute attacks and, if 
so, their nature. Still further, they should know 
whether the applicant has been the subject of renal 
colic, albuminuria or glycosuria, as any one of 
these conditions as a complication denotes that there 
is some disease of the kidneys or metabolism. 

Whenever a history of gout is acknowledged 
the urine and blood vessels should be examined 
with unusual care, and the hands and ears inspected 
for the presence of tophi. It is advisable to take 
the same precautions when an inherited diathesis 
is evident, though there has not been a typical 
attack of gout, as the inheritance sometimes mani- 
fests itself in such individuals by degeneration of 
the heart, blood vessels, and kidneys and may pro- 
voke changes in the nervous system. 

In order that the examiner may fully understand 
the importance of all these requirements, it may 
be added that the presumption is against the ac- 
ceptance of an applicant who has had gout. Ex- 
ceptions may be made when the family inclination to 
gout is not too marked, when the disease did not 
assert itself until after the applicant was thirty 
years of age, when there has not been more than 
two attacks, both of which were mild in character, 
and when the attack, or the last one if there were 
two, occurred at least five years previously, when 
there is an absence of renal colic, albuminuria, and 
glycosuria in the personal history, and when the 
habits of the applicant are abstemious both as to 
drinking and eating. 

It should never be forgotten when considering 
the question of gout, and this will explain the re- 
luctance of life insurance companies to insure those 
subject to this disease, that there is a strong lia- 
bility in these cases to the diseases of the blood 
vessels and kidneys which have become so promi- 
nent during the last lo or 15 years as agents for 

50 



PERSONAL HISTORY. 

shortening life. The bad results from the changes 
in these organs as well as in the nervous system are 
not apt to appear until after fifty years of age when 
the gouty attacks have been few in number and 
mild in character, and in these cases an endowment 
policy may be granted occasionally for the reason 
fully described in the explanation of the advan- 
tage gained in issuing endowment policies in the 
section on rheumatism. 

Syphilis. — Ascertain the date of initial lesion, 
the nature and approximate date of the secondary 
symptoms, the occurrence of any tertiary indica- 
tions, the date of the last manifestation of the 
disease and of last treatment. In order that the 
medical officers at the home office may get a true 
picture of the early conditions, they will some- 
times express the desire to have the applicant re- 
quested to furnish a statement from the only one 
in a position to give the information with authority 
— the attending physician. 

While insurance offices have somewhat different 
methods of dealing with this question, they are 
practically unanimous in their conclusions that syph- 
ilitic infection is a distinct prejudice to a proposer 
for insurance. In other words, if insurable at all, 
the person who has been subject to syphilis is not 
eligible to insurance at ordinary rates, but most 
companies will issue an endowment or a rated up 
policy if they have good evidence that the appli- 
cant took adequate treatment, that the disease was 
arrested in the secondary stage, and that a period 
of time, varying from three to five years, according 
to the conviction of the company interested, has 
elapsed since the last manifestation of the disease 
and the cessation of treatment. The free use of 
alcohol increases the hazard of these risks. 

Many cases have been observed by various au- 
thorities in which late constitutional symptoms fol- 
lowed what was supposed to be thorough early 
treatment. It must, therefore, be assumed that a 
large percentage of syphilitics will not live out 

51 



INSURANCE MEDICINE. 

their expectancy. The two chief elements in caus- 
ing loss in this class of proposers are vascular 
changes, especially of the arteries of the brain and 
heart, and diseases of the nervous system in the 
form of general paralysis of the insane and tabes 
dorsalis. Most of the deaths from cerebral apo- 
plexy, cerebral softening, sclerosis of the coronary 
arteries, and localized or general arteriosclerosis 
occurring before the age of fifty or fifty-five may 
justifiably be regarded as due to syphiHs. 

The issuance of an endowment policy that will 
mature between the ages of fifty to fifty-five, or of 
a policy rated up so that the premium will be 
large enough to protect the company against ex- 
cessive loss in insuring these applicants as a class 
if they die at the ages stated, is the only practice 
that may be pursued safely in assuming these risks. 

Before leaving this subject the examiner should 
be warned that some applicants will practise decep- 
tion when questioned in regard to this subject. The 
acknowledgment of any venereal sore should lead 
to a careful investigation with a report of all facts, 
even if the examiner is convinced that the lesion 
was a simple ulcer or chancroid. It may be expedi- 
ent to omit the history of a venereal disease from 
the report, as many applicants will object to having 
it written in the examination blank where it will be 
seen by other persons. In that case, the full infor- 
mation may be sent in a separate communication or 
confidential letter directly to the home office, but 
the examiner should mail it at once and in a care- 
fully addressed envelope. 

Abscess, Ulcer. — Give date, duration, nature, part 
affected, and recurrences if any. A full account 
of any surgical interference and pathological find- 
ings should accompany the report. The object of 
chief interest in these cases lies in the fact as to 
whether or not there was any suspicion of diabetes, 
syphilis, tuberculosis, or malignancy, and it may 
be necessary to have the applicant furnish a state- 
ment from the physician who had the opportunity 

52 



PERSONAL HISTORY. 

of observing the condition at the time of its occur- 
rence before doubt can be removed. 

Tumor. — Give the date, duration, nature, size, 
location, part involved, recurrence, and increase in 
size, if any, during the past two or three years. The 
examiner should always endeavor to secure a report 
of any pathological findings and surgical assistance. 
In these cases, also, it may be necessary to resort 
to a certificate from the attending physician or 
operating surgeon in order to clear up any suspi- 
cion of malignancy, tuberculosis or syphilis. 

Diseases of the Skin. — Give dates, duration, ex- 
tent, nature, parts involved, and number of attacks. 
The examiner will be expected to inquire closely 
into the nature of any skin trouble in order that he 
may determine whether it was a syphilide, tuber- 
culide, or of a malignant character. It may not be 
possible to clear up the matter satisfactorily until 
the attending physician is communicated with. 
When the disorder was of a benign nature, such 
as eczema or psoriasis, it is important to know 
the extent and location of the surface of the body 
involved, and when it still exists covering large 
areas, such as the entire trunk, or has recurred 
often, it is apt to be a sign of some dyscrasia or 
constitutional disturbance and possibly call for re- 
jection or the issuance of an endowment policy. 

Disease of the Nose. — The ordinary and simple 
catarrhal troubles, so prevalent, need not excite any 
comment, but there should be some inquiry as to 
whether the catarrh is of a more serious nature, 
whether there is any condition requiring surgical 
interference such as extensive malformations of the 
bony structures or polypi. If there is a history of 
polypi with removal, it is advisable to ascertain the 
number of recurrences, if any, and the date of the 
last operation, as from six to twelve months should 
elapse in these cases, according to the number of 
removals, before acceptance of the risk. 

Diseases of the Ear. — The chief trouble in the 
ear in which the life insurance companies are inter- 

53 



INSURANCE MEDICINE. 

esed is otorrhea, some being considerably more 
exacting than others. There has been some relax- 
ation in regard to the matter and it may be stated 
in a general way that these subjects may be insured 
when the discharge is neither bloody nor offensive, 
when it is not associated with pain or tenderness, 
when no granulations, polypi, or carious bone are 
present, and when the perforation is in the anterior 
lower segment of the drum, thus insuring good 
drainage. Most of these data can only be furnished 
after an examination of the ear has been made, and 
as the cases as a whole are not good risks, a state- 
ment from a competent aurist should be insisted 
upon before issuing a policy. Some companies do 
not accept such risks until at least two years have 
elapsed since the last appearance of any discharge. 
Extension of the inflammation to the tissues about 
the brain is not the only menace in otorrhea, as 
there is a fairly marked tendency to tuberculosis in 
those subject to it. 

Scrofula, Swelling or Suppuration of the Glands, 
— In most subjects with either one of these troubles, 
the condition is due to tuberculosis or a tendency to 
it, although it may arise from syphilis or lukemia. 
The examiner should, therefore, investigate care- 
fully into the personal history and obtain, when- 
ever possible, a report of any pathological ex- 
amination. 

Surgical Operations. — Give the date, diagnosis of 
the condition for which the operation was done, 
nature of the operation, the structures involved, the 
end result, any remaining effects, and state whether 
there was any suspicion of malignancy. It is often 
necessary to have the operating surgeon furnish a 
certificate covering these facts as well as any patho- 
logical findings, and v/hether there was any sus- 
picion of malignancy or tuberculosis. 

Deformities or Loss of Limbs. — When there has 
been an amputation of an arm or a leg, give the 
point at which the operation was done, especially 
when at shoulder or hip joint as this constitutes 

54 



PERSONAL HISTORY. 

an impairment in most cases. The condition of the 
stump should be looked into, and it should be stated 
whether or not the applicant uses crutches when 
the lower extremity or a part of it has been 
removed. 

In hip joint disease, try to find out if the original 
trouble was tubercular in character, and note care- 
fully the presence of any scars in the region of the 
joint. 

In spinal curvature, it is essential to know 
whether the curvature is lateral or anteroposterior, 
as the latter usually indicates former tuberculous 
disease. When the curvature is lateral, give some 
idea as to the amount of deformity and the amount 
of deviation by actual measurement from the 
median line, as many of these cases are acceptable 
if the deformity is not too great. 

Hernia. — When there is a hernia, ascertain if 
there has ever been any difficulty in reducing it or 
in maintaining it by means of a truss. 

Habits. — The question of the habits of an appli- 
cant from a life insurance point of view is confined 
to the use of alcohol or drugs. The subject is one of 
the most important in the selection of risks, and 
there is none that involves so much trouble and un- 
certainty on account of the strong inclination to sup- 
press and distort the truth, even among applicants 
who.se statements in other respects may be relied 
upon. This may be illustrated in part by the ex- 
perience of the writer who had a small degree of 
confidence at one time in a written statement signed 
by the applicant whose habits were questioned, in 
addition to the regular report, to the eflfect that his 
mode of life was all that could be desired. This 
faith was' soon dissipated, however, when subse- 
quent and reliable investigation revealed excessive 
indulgence by a good proportion of the individuals 
who had signed these declarations. 

An examiner, then, should not rely too much on 
the assertions of those who are suspected of using 
drugs or consuming an immoderate amount of alco- 

55 



INSURANCE MEDICINE. 

hoi. It is, unfortunately, necessary to ask him at 
times to make further inquiry, even though he has 
made a favorable report, when the company has 
reason to believe from other sources that the habits 
of the applicant are not what they ought to be. The 
examiner should give all the facts acquired in his 
investigation and may rest assured that information 
furnished by him will be treated as strictly confiden- 
tial. The company does not expect the examiner to 
act the part of a detective and he will, as a rule, 
be requested to investigate further only when he is 
personally acquainted with the applicant. Occasion- 
ally, however, even though the applicant is unknown 
to him, the examiner may be asked to make some in- 
quiry if the community in which they reside is a 
small one where everyone is more or less familiar 
with the affairs of others. Service of this' kind is 
included among the duties of the medical examiner, 
as he is depended upon to render all the assistance in 
his power toward guarding the interests of the com- 
pany and excluding poor risks. An examiner may 
have know^n an applicant for a considerable length 
of time and not be cognizant of any bad habits on the 
part of the latter. In this' event, inquiries conducted 
in a quiet, tactful way among mutual friends and 
business acquaintances will usually elicit the desired 
information. 

Alcohol. — It is not commonly contended that the 
individual who uses alcoholic beverages in a strictly 
moderate way is to any appreciable extent a less 
desirable risk than the total abstainer. The toler- 
ance of alcohol varies with the individual. One 
man may drink a glass or two of wine or spirits a 
day with impunity, while another can not indulge 
even to this extent without physical deterioration. 
It may be stated in a general way, however, that the 
total abstainer is less likely to become an intemperate 
user at a later date than the one who habitually 
drinks alcohol in moderation, for the former is les's 
exposed to the temptations of the bar-room, club, or 
the private closet in his home. The question arises, 

56 



PERSONAL HISTORY. ^ 

what constitutes strictly moderate drinking? Some 
men who pride themselves on their moderation 
would feel hurt at the suggestion that they drink 
more than is good for them, and yet are in the habit 
of taking five or six, or even more, drinks a day. 
These men are apt to resent close questioning when 
the examiner tries to get somie definite idea of the 
amount of alcohol consumed by them. Then, again, 
there are the individuals who go on several (three or 
four) short sprees' a year and drink little or nothing 
in the intervening period. It may be accepted that, 
as a rule, those who continuously indulge to the ex- 
tent of about five or six drinks a day without feeling 
any the worse for it are more likely, eventually, to 
suffer from ill effects of some kind than those who 
get drunk occasionally and leave alcohol alone in the 
interval. 

Immoderate drinkers of all classes should be re- 
jected, but, notwithstanding the great care taken by 
insurance companies to keep such applicants off the 
books, a number of them will succeed in securing 
policies owing to the difficulties already alluded to. 
The number of these undesirable risks' can only be 
kept down by maintaining a high standard among 
the examiners and agents, and in securing reports 
from other reliable sources. Part of the difficulty 
may be laid to the failure of medical examiners 
to agree on the question as to what constitutes 
strictly moderate drinking. Medical men who take 
five or six drinks a day themselves are inclined to 
adopt a complacent attitude towards the habits of 
those who indulge to the same extent or even a little 
more, while the abstaining examiner may be too 
severe on those who are really moderate drinkers. 
The examiner should state, as far as' possible, the 
actual daily quantity imbibed by the applicant, in- 
stead of using such ambiguous terms as "temper- 
ate'' or ''moderate." 

The kind of beverage us'ed seems to make little 
difference. Beer is popularly supposed to be less 
injurious, but this idea is poorly founded, and 

57 



INSURANCE MEDICINE. 

its fallacy is ably maintained in the following quo- 
tation from an article by the eminent actuary, 
Emory McClintock, the ultimate results of alcohol 
also being referred to in the remarks: ''Yet the 
difference between those who drink beer and thos'e 
who drink water is unmistakable, while the loss on 
beer drinkers has been almost the same as upon wine 
and spirit drinkers. Among wine and spirit drink- 
ers a large part of the extra loss* is upon actual 
drunkards, while the remainder must be ascribed to 
the injurious effects upon the constitution of sup- 
posedly moderate though really immoderate indul- 
gence. Among beer drinkers pretty much the whole 
of the extra loss, it would seem, must be attributed 
to constitutional effects. It is the danger of falling 
into the habit of intoxication that makes spirit 
drinking the more formidable of the two; while 
undoubtedly the habit of drinking either beer or 
wine or spirits beyond a certain medical limit, not 
well defined because it cannot be the same for all 
constitutions and usually exceeded by those who 
drink at all, tends in many cases towards diseas'e. 
Finally, it may be questioned very seriously whether 
the physicians should not fix their limit of safety 
for any individual at a lower point for beer, measur- 
ing by alcoholic contents, than for spirits' ; that is to 
say, whether there is not an injurious element in 
beer apart from the alcohol which it contains. 

''There is no reason to distrust the general results 
of this investigation. It coincides with all previous^ 
reasonable belief and expectation. It does not show 
that those who drink only occasionally and not to 
intoxication, or those who drink habitually but 
lightly, are in any way injured. It does not show 
that all of those who drink heavily must, therefore, 
necessarily die prematurely. It does' show, how- 
ever, that there is enough injury done to a sufficient 
number of individuals to make the death loss dis- 
tinctly higher on the average. Again, it is admitted 
that death losses in excess among drinkers are not 
neces'sarily due always to drink. The coincidence 

58 



PERSONAL HISTORY. 

between excessive drinking and lower vitality may 
be partly due to bad risks taking to drink, as well as 
to good risks becoming bad because of drink. On 
the whole, however, the teetotal habit, not only be- 
fore but after middle age, must be counted as a fa- 
vorable indication in judging of proposals for in- 
surance from persons' not known to be careful and 
moderate in the use of beverages." 

The well-considered conclusions of Mr. McClin- 
tock are emphasized by the experience of certain 
companies which divide their policy holders into 
abstaining and non-abstaining classes on the ground 
that it is' unfair for the former class to be penalized 
by paying the larger premium required to meet the 
greater mortality in the latter class. Dr. T. F. 
McMahon recently read an article (Medical Rec- 
ord, Vol. 80, No. 23) on the comparative mortality 
in these classes in the company which he represents. 
The statistics presented by him are practically the 
same as those gained from the experience of the 
other companies' working on similar lines, and are 
the more impressing because they deal with com- 
parison between total abstainers and strictly moder- 
ate drinkers and exclude immoderate drinkers as 
far as possible. In a resume of these statistics it is 
seen that during the 45 years from 1866 to 19 10 the 
number of actual death claims in the total-abstainer 
class was 8,988, as against 12,754 expected; in the 
non-abstaining clas's the actual number of deaths 
was 14,711, as against 15,794 expected. In other 
words, the percentage of actual to expected deaths 
in the abstainers' class was 70.47, while in the non- 
abstaining section it was 93.14. The mortality sav- 
ing in non-abstaining class was, therefore, 3,766 
lives during the 45 years, while that in the non- 
abstaining class, with a larger business, was only 
1,083 lives. If the loss ratio had been as high in 
the abstaining section as it was in the non-abstaining 
section the mortality saving would have been only 
87s lives instead of 3,766. If the loss ratio in the 
non-abstaining section had been as low as in the ab- 

59 



INSURANCE MEDICINE. 

stainers' section, the mortality s'aving would have 
been 4,664 lives instead of only 1,083. This makes 
the mortality saving an average of 4.3 times as great 
in the abstaining class as in that of the non- 
abstaining. The examiner can readily understand 
how poor a figure a clas's of those would cut who 
habitually drink five to seven times a day, if com- 
pared with even the non-abstainers' class referred to 
in the above figures' in which every effort is made 
to exclude those who are not strictly moderate in 
the use of alcohol. 

If the applicant has resorted to some form of 
cure for alcoholism, this' should be clearly reported, 
as well as any lapses or subsequent treatments. It 
is important to know, furthermore, whether the 
applicant has been a total abstainer at all times since 
the cure, as otherwis'e the risk should be rejected. 
Some Keeley graduates are insurable on an endow- 
ment plan if time enough has elapsed to indicate 
that there will be no lapse and the applicant has 
fully abstained from drink in the meantime. 

In his efforts to procure information the exam- 
iner will have to use all his tact and diplomacy, for 
these applicants will often resent any inquiry or will 
prevaricate in regard to their drinking. The ques- 
tioning should, therefore, be carried out in a good- 
natured way, as a brusque manner and a too-pointed 
cross-examination will often lead to the defeat of 
the examiner's efforts to obtain the facts. The 
same suggestion applies when the applicant's friends 
are approached, for if they become suspicious of 
the questioner's motives they are very apt to make 
light of the matter or refuse point blank to give any 
information. Before the authorities at the home 
office can act on these cases they must have in their 
possession a full knowledge of the number of 
drinks cons'umed daily by the applicant, the maxi- 
mum amount taken in any one day, the number of 
times, if any, he has been intoxicated, and the date 
of last intoxication. 

Drugs. — Detection of the drug habit is more diffi- 

60 



PERSONAL HISTORY. 

cult than in the case of the immoderate use of 
alcohol. A drug habitue will usually lie without the 
least compunction or hesitation in regard to his 
w^eakness, and the examiner must, therefore, depend 
largely in his' conclusions upon the general appear- 
ance and behavior of the applicant and upon current 
gossip. These unfortunates are especially bad risks 
on account of the wretched condition which awaits 
them and because the possibility of any escape from 
or effectual resistance to the intense longing become^ 
more and more remote as the quantity of the drug is 
inevitably increased while the mental and physical 
forces weaken. For some time after the habit has 
fastened itself upon the victim, there is little or no 
outward sign. Sooner or later, however, symptoms' 
begin to appear in the form of colorless, sometimes 
clammy, skin, averted looks, contracted pupils, ner- 
vous irritability, or mental and physical lassitude. 
The presence of one or more of these signs s'hould 
arouse the suspicion of the examiner and inspire 
him to look further into the habits of applicant ; also 
to inspect the shoulders and arms for the presence 
of s'cars from the use of the hypodermic syringe. 



01 



FAMILY HISTORY 

The examiners in the field will more fully under- 
stand the importance of securing accurate family 
histories if they possess some knowledge of the 
ideas entertained at the home offices on this sub- 
ject. It would not be strange if many examiners 
were laboring under hazy impressions when there 
is some difference of opinion even among medical 
directors as to the precise bearing of family records 
upon the selection of risks, some regarding the 
family history as highly important while others 
prefer to be guided mainly by the personal history 
and physical condition of the applicant. On the 
whole, as will be seen later on, there can be little 
doubt as to the advantage gained from the con- 
sideration of the average length of life of the 
ancestors and collaterals and of any decided mor- 
tality among them from certain diseases, and it is, 
therefore, a safe plan to regard both the family 
and the individual traits. 

Undoubtedly many individuals defeat their bane- 
ful inheritance through the subjugation of their 
desires and passions for excesses of all kinds, by 
living in a favorable environment and following a 
suitable vocation. If all men could and would ob- 
serve these and similar wise precautions in a thor- 
ough and conscientious way the question of family 
history might be largely disregarded, but as long 
as the uncertainties of fortune, environment, and 
domestic relations continued, the majority of even 
those anxious to escape their tainted inheritances 
will find themselves more or less prevented from 
leading appropriate lives. On the other hand, some 
men who have not lived prudently do reach ad- 
vanced age though their families have been almost 

^2 



FAMILY HISTORY. 

annihilated by some disease; the survival under 
these circumstances may be attributed to a rever- 
sionary inheritance from some vigorous and robust 
ancestor. 

Tuberculosis plays the chief role in the trans- 
mission of the tendency to disease, but even in 
these cases precautionary measures when open to 
contagion, favorable surroundings, freedom from 
exposure, a healthy occupation, and strict temper- 
ance will greatly modify the danger of contraction 
of the disease. Volumes of statistics in regard to 
the relation between family history and the con- 
traction of consumption have appeared. Those 
compiled by Dr. Marsh (article read at the sixth 
annual meeting of the Association of Medical 
Directors) will clearly illustrate the question at 
issue. Dr. Marsh gives an estimate of the liability 
to consumption based upon an analysis of 1994 
deaths of persons with a tainted record and 2706 
cases with an untainted record. With the con- 
sumptive mortality among the non-tainted class as 
a basis, the proportion was increased 30 per cent, 
in the tainted class. There were only a few cases 
in which both parents had been consumptive and 
in these the experience had not been particularly 
unfavorable, probably on account of the fact that 
the wife or husband contracted the disease in 
many instances while nursing the other; the same 
result was shown when a parent and a brother 
or sister had died. The proportion of consumption 
was greatest when two or more brothers or sisters 
had died. The table of cases with tainted record 
showed a larger amount of consumption in both 
those above and below the average weight, but 
there were twice as many consumptive deaths in 
those below as in those above the average. Dr. 
Marsh's diagrams indicate that a good weight 
overbalances a tainted family history to a marked 
degree. It may be added that these estimates may 
fall short of the mark because they consider only 
those dying from consumption, v>rhile it is generally 

63 



INSURANCE MEDICINE. 

conceded that there is a greater tendency to die 
from other diseases as well as from consumption 
among those who have that taint in their family 
record. 

Another class is composed of those who acquire 
consumption, though no tendency to the trouble is 
indicated by the family history. It must be remem- 
bered, however, that some persons wilfully mis- 
represent the causes of death, and others have no 
accurate knowledge or give the causes as they 
understand them from the family traditions, the 
real cause of death having been consumption but 
gradually changed by members of the family to 
some less dreaded disease. 

Childbirth is frequently offered as a cause of 
death. It has been found from the records that the 
death of the mother from childbirth has as unfavor- 
able an influence upon the longevity of her children 
as when the death is said to have been consump- 
tion. The best explanation of this is that the 
mother was really a victim to tuberculosis with the 
consequent inability to go through the ordeal of 
labor. This is so well understood by the medical 
staffs at the home offices that they will usually 
regard childbirth in the same light as tuberculosis 
in such cases, whenever the risk is a doubtful one 
otherwise. 

It is common to find that families in which the 
members lived to good ages bring forth individuals 
possessing a high degree of vital elasticity and in- 
creased resistance to disease which no amount of 
personal care can give them. On the other hand, 
poorly bred men yield to som^e disease, not so much 
because their ancestors died from that particular 
trouble as that they inherit a weak power of resist- 
ance and a low vitality through which they suc- 
cumb readily when exposed to the bacilli of tuber- 
culosis, or are attacked by some other disease. A 
study of death claims shows that a large number 
of men with tainted family record do not die from 
the diseases they were expected to inherit from their 

64 



FAMILY HISTORY. 

parents or grandparents, but that many of them 
die, nevertheless, at a more or less immature age. 
Consumption, cancer, Bright's, cardiac disease, 
apoplexy, epilepsy, insanity, diabetes and the 
alcohol or drug habit are disorders which carry 
off these descendants, and which occur as inter- 
changeable inheritances. So it is that a family 
record showing a poor longevity affects the de- 
cision at the home office in doubtful cases such 
as those with an impaired personal history or with 
weight outside the normal limits and may afford 
sufficient justification for rejection or for the issu- 
ance of an endowment policy in which the con- 
tract terminates at a certain age. 

The family history has been discussed as far as 
space allows in order that examiners will fully 
realize the importance of a searching inquiry into 
the causes of death. The following suggestions are 
offered : 

I. In eliciting the family record always ques- 
tion the applicant carefully and specifically as to 
whether there was any suspicion of tuberculosis, 
insanity, epilepsy, paralysis, or cancer in any mem- 
ber of his family, and the ages at which each one 
of them died. This inquiry should only extend 
far enough to include grandparents, parents, 
brothers and sisters, as this will provide sufficient 
data for all practical purposes. 

2. The statement that parents, brothers or sis- 
ters have died of "old age,'' ''exposure," ''child- 
birth,'' "change of life," "dont know," and similar 
ambiguous causes of death so often given to gloss 
over the real troubles should only be accepted in the 
few cases where the applicant is really ignorant of 
the nature of the diseases and the exact ages of his 
near relatives at the time of their death. In such 
instances the examiner should explain this fact 
explicitly. 

3. A special effort should be made to ascer- 
tain the true cause of death when the applicant i's 
under the standard weight or there is a personal 

65 



INSURANCE MEDICINE. 

history of hemoptysis or pulmonary troubles. If 
it is admitted in these cases that one or more mem- 
bers of the family died from pneumonia, childbirth, 
or some chronic ailment, the direct and specific ques- 
tion should be asked as to whether there was any 
suspicion of tuberculosis in the illness. Even then 
some doubt will remain occasionally and may be 
cleared up by drawing out further details concern- 
ing the condition previous to death, i.e,, whether 
there were gradual wasting away and other symp- 
toms of consumption. 

Moreover, negative as well as affirmative answers 
should be indicated in the medical report to show 
that these specific questions have been asked and 
in this way obviate the necessity of correspondence 
from the home office to clear up the doubtful points. 

4. Half brothers and sisters should always be in- 
cluded in the family record and such relationship 
stated. 



66 



Chapter III. 

THE PHYSICAL EXAMINATION. 

The reader is referred to the many excellent text- 
books for the details of physical diagnosis, as it is 
the writer's desire to limit the suggestions in this 
and following contributions to the practical points 
which arise in connection with examinations for life 
insurance. 

General Methods. — A strong and persevering 
effort during about the last ten years to raise the 
standard of life insurance examinations has been 
rewarded with substantial success. The quality of 
this work is now of the high order that would natur- 
ally be expected from the class of men who represent 
the different companies, but it still remains true that 
the best of examiners will occasionally forget the 
importance of scrupulous care and constant vigi- 
lance in their examinations when pressed by the 
other numerous duties incident to the life of a 
busy practitioner. Then, again, though the major- 
ity of examiners are men of recognized integrity 
and ability, candor compels medical men themselves 
to admit that the efforts of some of their poorly 
equipped or weak fellow-practitioners have not 
always reflected credit on the profession, either in 
their capacity as the family physician or as a life 
insurance medical examiner. The writer has been 
interested for a good many years in the improve- 
ment of the medical situation in so far as it related 
to life insurance medicine, and some of his per- 
sonal experience may interest, it certainly will sur- 
prise, most examiners by showing to how low a 
plane poor work of this kind may reach and what 

(>7 



INSURANCE MEDICINE. 

the companies have had to contend with in some 
locaHties. The conditions referred to were usually 
encountered in sections of the country where cir- 
cumstances, chiefly financial, forced men up to the 
last few years to seek a medical training in the local 
mushroom colleges which disgraced the land, espe- 
cially twenty or thirty years ago. Graduates from 
concerns of this kind were sent out with the most 
superficial ideas of physical diagnosis, and if they 
were not tremendously inspired with ambition and 
also settled in obscure places where they missed 
the advantages of interchange of thoughts with bet- 
ter equipped men, they almost inevitably fell into 
deep ruts of empiricism, treating fevers with 
calomel and quinine irrespective of the nature of 
the disease which they rarely understood. With 
age and personality in their favor these men were 
often regarded as the most prominent physicians 
in their neighborhood, yet it was not uncommon 
to find them without the faintest idea of the re- 
quirements of physical examination or urinalysis, 
or even the necessary apparatus. They seldom re- 
quired the applicant to remove the coat or vest for 
the examination, or, still worse, omitted the cere- 
mony of a physical examination and urinalysis alto- 
gether, this complacent and congenial frame of 
mind arising especially when the examiner and the 
applicant were friends or fellow-members of some 
order or society. The names of these men have 
gradually disappeared from the lists in the endless 
weeding-out process and been replaced by those of 
examiners with a higher sense of duty and better 
qualifications. 

The examination of an applicant is of little value 
unless it is carefully and completely made under 
the following favorable conditions : 

I. Privacy. — The advantages of privacy are ob- 
vious; namely, that there will be no hindrance to 
the applicant giving out information that he would 
hesitate to impart in the presence of other persons, 
and there will also be no disturbing element to dis- 

68 



THE PHYSICAL EXAMINATION. 

tract the mind of the examiner. Privacy should 
always be insisted upon. The only exception is in 
the case of a woman applicant, in which event the 
presence of some friend during the physical ex- 
amination after the questions have been answered is 
permissible. 

2. Absence of Noise and Bustle. — This will not 
only help the ear of the examiner but will also al- 
low him to concentrate his faculties on the work 
in hand. The action of the examiner will be upheld 
by the home office if he refuses to go on with the 
examination until a suitable place is selected. 

3. The Removal and Proper Arrangement of the 
Applicant's Clothing. — The best of diagnosticians 
and the keenest of ears will surely fail at times to 
detect some of the signs of disease through thick 
clothing, especially in the early stages of pulmo- 
nary lesions and in some forms of heart disease. 
Moreover, the clothing interferes with ocular in- 
spection, palpation, and percussion. Nevertheless, 
the writer ventures the statement that fully 50 per 
cent, of examinations are made through thick 
undershirts, two shirts one of which is often 
starched, or even through shirts and vest. The fear 
of offending the applicant by asking him or her 
to remove sufficient clothing to permit an examina- 
tion of any value often deters the examiner from 
making the request. This danger is purely an 
imaginary one provided the examiner goes about it 
in a calm, polite and diplomatic way. Home office 
examiners whose duty brings them in contact with 
thousands of applicants of both sexes in their homes 
or at their places of business, invariably and with- 
out any exception secure enough exposure of the 
chest and abdomen to insure the proper conditions, 
and this arrangement is always cheerfully assented 
to without any visible signs of annoyance or ir- 
ritation. The best method for arranging the cloth- 
ing is shown in the illustration on page 70. 

Having removed the coat and vest, the suspen- 
ders are dropped. Both shirts are then rolled up 

69 



INSURANCE MEDICINE. 

to the level of the clavicles and held there by the 
applicant, leaving the examiner free to proceed with 
his examination of the chest and abdomen. In 
doubtful cases or when a starched shirt is worn, it 




When photographing the subject for the original of this cut, the 
chest was so completely exposed that the stethoscope could be ap- 
plied directly over the apices without touching any clothing. 



may occasionally be necessary to ask the applicant to 
remove the outer shirt so as to allow a thorough 
auscultation at the apices. In most cases, however, 
the first procedure of rolling the shirts up will meet 

70 



THE PHYSICAL EXAMINATION. 

all requirements. When examining the back the 
shirts are similarly rolled up, the applicant holding 
them by a hand extended back over each shoulder. 
When women are to be examined there should be 
no clothing above the waist other than a sack or 
robe of some stuff thin enough to allow a satisfac- 
tory examination. Corsets should invariably be re- 
moved. The writer has examined hundreds of 
women in all classes of society and has never ex- 
perienced any difficulty in having his requests for 
such an arrangement cheerfully granted. 

The examiner should always remember that the 
home office authorities are too pressed for time to 
be interested in his mental processes. It is their 
function to secure information as to whether or not 
the applicant is insurable and they will usually en- 
tertain a feeling of gratitude toward the examiner 
who limits his answers to *'yes'' or *'no" or to 
short concise ones if some further explanation is 
necessary. Nothing is gained when an examiner 
theorizes on or reports some condition which, while 
it is not exactly according to rule, is not pathologi- 
cal to the slightest degree, such as, for instance, the 
occasional difference found on percussion or auscul- 
tation between the sides of healthy chests, a purely 
cardio-respiratory heart murmur, and many others. 
As long as the examiner thinks such statements are 
important enough to appear in the medical report, 
they must be noted at the home office and the mat- 
ter cleared up through further correspondence with 
consequent delay. The examiner is depended upon 
to ascertain whether or not the irregularity is 
caused by some pathological lesion or by some con- 
dition actually detrimental to the applicant as an 
insurance risk. There may be reasonable doubt in 
which case he is always entitled to as much time as 
he needs and he is justified under such circum- 
stances in requesting further interviews with the 
applicant in order that he may ascertain the real 
nature of the trouble; but when he has made up 
his mind definitely he should simply report any ab- 

71 



INSURANCE MEDICINE. 

normality present or recommend the risk, as a rule, 
without further comment. If the examiner with 
the applicant before him and his ear to the chest is 
not able to arrive at a conclusion, the medical di- 
rector at his desk will hardly be in a position to 
come to any decision with only indefinite or am- 
biguous statements before him. 

Figure. — An applicant may be erect, vigorous, 
muscular, and compact, or, on the other hand, he 
may be so stooped, frail, thin, emaciated, fat, or de- 
formed that he is not entitled to life insurance. 
If, however, the applicant is thin, but still healthy 
and wiry, or if he is an overweight but muscular 
and with fat evenly distributed, or if he is stooped 
from the habit of carrying himself in that way or 
as a result of his occupation, these modifying facts 
should be clearly described in the medical report. 

General Appearance. — The general appear- 
ance of a man is an important matter and a close, 
keen inspection may enable the examiner to recog- 
nize slight signs of existing physical weakness, 
previously unsuspected. Examiners of considerable 
experience and observation place due confidence 
in the conclusions deduced from a careful survey 
of the general aspect of the applicant, and though 
they may be at a loss at times to give an adequate 
reason, their impressions, nevertheless, are entitled 
to respect. In other words, a case is occasionally 
encountered in which the appearance indicates 
more or less ill health and yet it is difficult or im- 
possible to locate the focus of the disturbance, no 
matter how carefully and rigidly the examination 
is made. Under such circumstances the examiner 
is justified in recommending rejection or postpone- 
mxent on the ground that the unfavorable appear- 
ance is the result of some obscure or latent disease. 

The condition known as a ''healthy appearance" 
cannot be defined clearly, for while it is evident 
to all that a strong vitality and a robust constitution 
are usually indicated by the complexion and tone of 
the tissues, there are several grades of appearance 

72 



THE PHYSICAL EXAMINATION. 

between that of the clean-cut, robust individual 
with an abundance of muscle and one who is unin- 
surable on account of the presence of any earmarks 
of disease. A company which limited its business 
to athletes and risks first class in every respect 
would find its field very limited and needlessly so, 
as applicants of this kind have no better longevity 
as a class, other things being equal, than those of 
average health and who, perhaps, are sedentary in 
their habits to a moderate degree and consequently 
without much muscular development or signs of 
unusual vigor. 

The salient points to be observed in estimating 
the quality of the risk from the general appearance 
are described in the following paragraphs : 

The Term ''Fair/' — The use of the term *'fair" 
is strongly condemned; it should never be em- 
ployed in reference to the general appearance or 
in any other part of the medical report. It is too 
elastic and ambiguous and has no decided sig- 
nificance except to the one who uses it, and he will 
therefore always be requested to explain his un- 
derstanding of the word as it applies to the indi- 
vidual case through further correspondence. The 
examiner has the advantage of inspecting the ap- 
plicant personally, and he is expected to determine 
whether the risk is acceptable or not and, further, 
to express his opinion in a way that will leave no 
doubt at the home office. If the examiner cannot 
form a definite conclusion, the medical directors 
who must judge the case entirely on paper will be 
in a poor position to do so. 

Pallor. — When the applicant is noticeably pale, 
ascertain whether it is due merely to indoor occu- 
pation or an inherited complexion, or to anemia 
or some other disease, and be sure to report the 
findings explicitly. 

Whenever the word ''pale'' is used in the report, 
the cause should be given at the same time, as the 
pallor may or may not be significant. 

A pale face with dark rings under the eyes may 

73 



INSURANCE MEDICINE. 

simply be an indication for a needed rest and 
change of air. If, however, the pallor is accom- 
panied by a tired look, a dull skin, a gray drawn 
countenance, and gray hair, it may denote that con- 
tinued hard work and worry have brought on pre- 
mature old age and should prompt the examiner 
to make a search for thickening or hardening of 
the arteries. In either event, the pallor should be 
reported and the cause clearly described. 

Plethoric Appearance. — Do not make the mis- 
take of judging that the fresh complexion or even 
a full, flushed face is always due to plethora. Ex- 
posure to air will cause this even to the extent of 
dilated capillaries. On the other hand, it is true 
that the dilated capillaries may arise from high 
living with too much food and wine. In the latter 
case the examiner should consider the matter care- 
fully before referring to the condition as one of 
''apoplectic tendency." 

It should always be remembered that some of 
those addicted to the excessive use of alcohol have 
very little color as a result — in fact, they may have 
a full, flabby, pale face, but they are also apt to 
have pufliness under the eyelids, a glassy, watery 
eye, and a dull, nervous expression. Acne rosacea, 
though frequently associated with excessive alco- 
holic habits, is also common in digestive disorders 
and during the menopause in women. 

Jaundice or Sallowness. — Either of these con- 
ditions should lead the examiner to inquire as to 
whether there is any history, past or present, of 
gastrointestinal disorders or gall-bladder troubles, 
and the result should be clearly stated in the report. 

General Build, — Observe whether the applicant 
is muscular, thin, corpulent, or flabby. If he is an 
overweight, state if there is any excessive accumu- 
lation of fat on the abdomen. 

Apparent Age. — A man's prospects of life are 
not gauged by his age in years so much as by the 
actual age of his tissues which is usually shown 
by the general appearance and by the condition of 

74 



THE PHYSICAL EXAMINATION. 

his arteries. Some people are relatively older at 
45 than others at 55 or 60, the decline of life be- 
ginning at periods which vary with the amount of 
inherited or acquired vigor of the individual. Pre- 
mature senility is a distinctly unfavorable feature 
and a condition which will probably be encountered 
more often in the future than in past years on 
account of increasing business and social stress 
with the attendant degenerative changes. When 
there is a marked discrepancy between the given 
and apparent ages, it should be reported. A dif- 
ference of a comparatively few years, however, 
may be due to an unkempt appearance, the same 
individual looking considerably younger after a 
visit to the barber and the wash basin. Further- 
more, in doubtful cases, where the discrepancy is 
a slight one, there would be quite a difference in 
opinion among several observers as to whether or 
not the applicant looks older than the given age. 

Another question arising when the applicant 
looks older than the given age is whether or not 
he has given a younger age than the true one in 
order to obtain a policy with a lower premium rate 
than he is entitled to. 

Race. — Do not confuse race with nationality in 
answering this question. It is a common error to 
state that the applicant is "American,'' the examiner 
seeming to forget that this answer does not con- 
vey the information to the company as to whether 
the proposer is a white, negro, mulatto, or Indian. 

Height, Measurements and Weight. — The 
measurements and weight should never be regarded 
lightly as, in many cases, they hold a very important 
place in the list of facts and conditions which must 
be considered in the selection of risks. Accuracy 
is imperative in order to avoid an injustice to the 
companji or the applicant, as the case may be. 
Every examiner should, therefore, provide himself 
with a good tape measure and he should never fail 
to resort to the scales when meeting the conditions 
described further on. The best tape measures are 

75 



INSURANCE MEDICINE. 

those made of steel and the task of measuring the 
height will be facilitated if they are six feet in 
length. 

A great many faulty measurements are reported 
to the home offices. Errors will not occur in the find- 
ings of this purely mechanical procedure if the fol- 
lowing suggestions, w^hich are definite and observed 
by most examiners of wide experience, are adopted. 

Measuring the Height. — The height of the ap- 
plicant should be determined accurately by measure- 
ment and never estimated. Many of the scales 
made for physicians' offices are provided wnth a de- 
vice for ascertaining the height, but when this is 
not available the good old custom will answer of 
having the subject stand with his back to the wall, 
preferably on a wooden floor rather than a carpeted 
one, with some straight object, such as a book or 
ruler, reaching horizontally from the top of the head 
to the wall to indicate the proper spot to mark for the 
height. The height should be taken with the shoes 
on, as the tables of comparative height and weight 
are compiled with this addition to the height in mind. 

If the applicant is near or beyond the upper 
limit of normal weight, care should be taken to have 
him stand erect so that he may be credited with 
every inch or part thereof he is entitled to. Undue 
straining or standing upon the balls of the feet 
should not be allowed ; but, on the other hand, some 
stout individual who has the habit of carrying him- 
self in a more or less stooped position, might jeop- 
ardize his chances for obtaining insurance on the 
plan applied for or even on any plan whatever if 
the examiner did not prompt him to stand firmly 
and fairly erect. 

Measurements of the Chest and Abdomen. — 
Accuracy in these measurements is of special im- 
portance in the examination of overweights, as so 
much depends in these cases upon the measurements 
of the chest compared with those of the abdomen. 
The frequent discrepancies between the measure- 
ments by different examiners of the same subject 

76 



THE PHYSICAL EXAMINATION. 

is a matter of comment at the home offices as indi- 
cating a lack of care and uniformity; they may 
easily be avoided if all examiners adopt a common 
and approved method. 

Always take the measurements on the bare skin. 
This procedure is easily accomplished if the trunk 
of the applicant is exposed in the manner described 
in a preceding chapter, for the examiner may then 
eliminate the errors arising from including more 
or less of the clothing. If this precaution is not 
observed, the measurements of the chest may be 
made over a thin shirt while that of the abdomen 
includes a part of the thick trousers and under- 
clothing. 

The Chest. — The chest should be measured at the 
nipple line, the tape measure being carried horizon- 
tally around the body. 

When the applicant is a woman a measurement at 
the level of the nipples will not ordinarily be a fair 
one for two reasons, the thickness of the breast at 
that point and the lower position on the chest w^all 
occupied by the nipples when the breasts are pen- 
dulous. The proper course to pursue in such an in- 
stance is to carry the tape measure around the body 
just high enough to avoid the thick part of the 
breasts. 

Even in the case of a woman it would be better 
to measure the chest and abdomen next to the bare 
skin if the applicant is a heavy weight. When, 
how^ever, there is a woman with a pendulous abdo- 
men to contend with, the examiner may find it im- 
practicable to secure sufficient exposure of the body 
for him to carry the tape line over the umbilicus 
next to the bare skin. Therefore, if nothing must 
be worn, and as both the chest and abdominal meas- 
urement should be taken over the same amount of 
clothing, the applicant should properly prepare her- 
self for the examination by wearing a loose flowing 
gown of thin, light material. 

Examiners will not infrequently meet large, 
lusty fellows who are unable to show an expansion 

77 



INSURANCE MEDICINE. 

of more than half an inch or an inch notwithstand- 
ing strong but futile efforts. The same individuals 
will usually gain an inch or more of expansion with- 
out undue exertion after a bit of coaching. It is 
especially desirable to get all the expansion the ap- 
plicant is capable of in overweights, as the compari- 
son of the measurement of the expanded chest 
with that of the abdomen may exert a strong influ- 
ence on the final action at the home office. Exam- 
iners are often asked to remeasure the applicant 
and it is a common experience for them to find that 
they did not succeed in getting a full expansion the 
first time. The significance of these measurements 
will be more fully discussed later under the subject 
of ''overweights" as a class. 

The Abdomen. — More errors take place in meas- 
urements of the abdomen than in any of the others. 
This lack of accuracy, while of little consequence 
in the case of normal abdomens, gives rise to much 
trouble and extra correspondence when the appli- 
cations of overweights are under consideration. 
Special attention is directed to the following sug- 
gestions : 

First — The abdominal measurement should al- 
ways include the umbilicus. The application blanks 
should call for this, and in the few" which only men- 
tion the waist line it is probably assumed that the 
instructions apply only when the navel is in its 
proper location. As a matter of fact, the abdomens 
so unpopular at the home offices are those loaded 
with an accumulation of fat as a result of which 
they are apt to be pendulous with the umbilicus well 
below the waist line and on a level with the upper 
part of the buttocks. 

Second — The buttocks and the crests of the ilia 
should never be included in the abdominal measure- 
ment. Failure to observe this precaution is a too 
frequent occurrence and leads to the reporting of 
a measurement far in excess of the true one, even 
in fat subjects. 

Third — The rule for measuring in a horizontal 

78 



THE PHYSICAL EXAMINATION. 

line will have to be departed from when dealing with 
a pendulous abdomen which has carried the umbili- 
cus below the level of the crests of the ilia. In 
these cases the tape line should be carried obliquely 
from a point on the back just high enough to escape 
the crests and low enough in front to reach the 
navel. In other words, the fat applicant with a 
pendulous belly must quite properly pay a penalty 
by having his abdominal measurement taken in an 
oblique line. When it is necessary to resort to this 
plan of measurement the examiner should mention 
it in his report. 

Fourth — All chest and abdominal measurements 
of heavy weights should be taken next to the bare 
skin in order that the comparison in these cases may 
be based on accurate figures. 

Fifth — Women are apt to have pendulous abdo- 
mens after pregnancy. In such cases two measure- 
ments should be taken ; one horizontally at the waist 
line, and the other in an oblique direction from a 
point on the back high enough for the tape-line to 
escape the iliac crests and low enough in front to 
include the umbilicus. Both measurements and the 
reason for taking them should be clearly described 
in the report, as a penalty is not exacted from a 
woman for having a pendulous abdomen as a re- 
sult of labor unless there is also an excessive accu- 
mulation of fat. If, however, the woman is over 
the normal limit of weight and the measurement 
over the umbilicus is partly increased on account of 
adiposity, this fact should be invariably stated in the 
report. 

It may be difficult to obtain a measurement next 
to the bare skin when the woman's abdomen is very 
pendulous on account of the great amount of ex- 
posure demanded. In the event of such an appli- 
cant being an overweight, she should be previously 
requested to limit her clothing to a gown of light 
material, and to especially exclude the many articles 
of underwear which extend downward from the 
waist. Very few women will refuse to prepare 

79 



INSURANCE MEDICINE. 

themselves properly for the examination if the mat- 
ter is tactfully and courteously explained to them. 

Sixth — When drawing the tape together, use the 
same degree of tension in taking the chest and ab- 
dominal measurements. 

Seventh — Some agents will train an applicant to 
draw in his abdomen while the examiner is trying to 
measure him. This trick is easily detected and 
must never be permitted. 

Eighth — The possibility of an abdominal tumor 
or ascites should be kept in mind when an excessive 
abdominal measurement is encountered. A definite 
statement as to whether or not one of these condi- 
tions exists, or whether the measurement is due 
to adiposity should be included in the report. 

Weight. — The weight should be taken with the 
ordinary clothing on, including coat and vest, as the 
figures given in the tables are computed with this 
extra weight in mind. 

The weight should be ascertained by scales when- 
ever possible. Oftentimes, however, no scales will 
be at hand and under such circumstances the weight 
must be estimated. When the weight is near the 
standard the need of actual weighing is not so great ; 
but there should be no doubt in the examiner's mind 
as to the importance of resorting to the scales when 
it approaches the neighborhood of or exceeds the 
limit under or above the standard. It is no easy 
matter to estimate the weight of heavy people cor- 
rectly as so much depends on the quality of the tis- 
sues, and it is not uncommon for the examiner, who 
has subsequently been requested to weigh the ap- 
plicant, to find a weight twenty to fifty pounds more 
than that given in his estimate in the original report. 

An examiner will invariably be requested by the 
home oflfice to weigh applicants who are near or 
beyond the limits set forth in the tables, if he has 
not already done so. It will, therefore, save time 
and correspondence if he attends to this require- 
ment in the first place. 

Table of Heights and Weights for Men. 

80 



THE PHYSICAL EXAMINATION. 

— A proper relation of weight with height 
and age should be required when selecting a 
certain group of risks, otherwise the mortality 
in that group will be too high in spite of the 
utmost care which may have been exercised in 
excluding other unfavorable elements. The com- 
panies have adopted approximately uniform tables 
for determining this' relation, and as so much 
emphasis is directed to the subject the examiner 
ought to have some knowledge of its funda- 
mental principles instead of harboring, possibly, the 
belief that it is merely a mass of arbitrary rulings. 
In the earliest tables, compiled in i83'6, one weight 
and one height is given for each age, and these are 
supposed to be the average height and weight for 
that age. They are imperfect but still agree fairly 
well with our present standard and se^-ved as a 
starting point. In 1846 Hutchinson published a 
table of heights and weights based upon certain data 
gathered in England and which purports to repre- 
sent the standard weight for each height at the age 
of 30. Compared with the present standard the 
weights in this table are too light for the shorter and 
too heavy for the taller heights. Other tables have 
been constructed with more or less consideration 
given to the influence of age, but the number of in- 
dividuals observed was too small for authentic re- 
sults. Finally, in 1897, Dr. George R. Shepherd 
offered some accurate and definite conclusions to 
the Association of Life Insurance Medical Directors 
in the form of a table of heights and weights for 
each quinquennium of age from 15 to 69, based upon 
an observation of 74,162 accepted male applicants 
for life insurance in the United States and Canada. 
The weights and heights include the clothing and 
shoes, so that the conditions are the same as those 
under which the applicants present thems'elves to 
the medical examiners. The table seemed so com- 
plete and accurate that it was adopted by the leading 
life insurance companies and, with occasional slight 

81 



INSURANCE MEDICINE. 



modifications made in accordance with individual 
opinions, is still in use. 

HEIGHTS AND WEIGHTS OF MEN AT DIFFERENT AGES. 





15-24 


25-29 


30-34 


35-39 


40-44 


45-49 


50-54 


55-59 


60-64 


65-69 


5' 0''.. 


120 


125 


128 


131 


133 


134 


134 


134 


131 




r.. 


122 


126 


129 


131 


134 


136 


136 


136 


134 




2".. 


124 


128 


131 


133 


136 


138 


138 


138 


137 




3^. 


127 


131 


134 


136 


139 


141 


141 


141 


140 


140 


^r.. 


131 


135 


138 


140 


143 


144 


145 


145 


144 


143 


5*.. 


134 


138 


141 


143 


146 


147 


149 


149 


148 


147 


t".. 


138 


142 


145 


147 


150 


151 


153 


153 


153 


151 


r.. 


142 


147 


150 


152 


155 


156 


158 


158 


158 


156 


8*.. 


146 


151 


154 


157 


160 


161 


163 


163 


163 


162 


9" .. 


150 


155 


159 


162 


165 


166 


167 


168 


168 


168 


10^'.. 


154 


159 


164 


167 


170 


171 


172 


173 


174 


174 


ir.. 


159 


164 


169 


173 


175 


177 


177 


178 


180 


180 


6' 0''.. 


165 


170 


175 


179 


180 


183 


182 


183 


185 


185 


v.. 


170 


177 


181 


185 


186 


189 


188 


189 


189 


189 


2".. 


176 


184 


188 


192 


194 


196 


194 


194 


192 


192 


y . . 


181 


190 


195 


200 


203 


204 


201 


198 













Table of Heights and Weights for Women. 
— The weights of women were roughly estimated 
formerly by assuming that they were 6 to 9 
pounds less than men at the age of 25, and 
that this' difference gradually diminished until it 
practically disappeared after the age of 45 or 50. 
As authentic figures were not available, this crude 
and unsatisfactory method was the one commonly 
resorted to until a few years ago. A table, based 

HEIGHTS AND WEIGHTS OF WOMEN AT DIFFERENT AGES. 



Height 


5 15-19 


20-24 


25-29 


30-34 


35-39 


40-44 


45-49 


50-54 


55-59 


60-64 


4'1V\. 


111 


113 


115 


117 


119 


122 


125 


128 


128 


126 


5' 0".. 


113 


114 


117 


119 


122 


125 


128 


130 


131 


129 


1".. 


115 


116 


118 


121 


124 


128 


131 


133 


134 


132 


2\. 


117 


118 


120 


123 


127 


132 


134 


137 


137 


136 


3".. 


120 


122 


124 


127 


131 


135 


138 


141 


141 


140 


4".. 


123 


125 


127 


130 


134 


138 


142 


145 


145 


144 


5".. 


125 


128 


131 


135 


139 


143 


147 


149 


149 


148 


6".. 


128 


132 


135 


139 


143 


146 


151 


153 


153 


152 


7".. 


132 


135 


^ 139 


143 


147 


150 


154 


157 


156 


155 


8".. 


136 


140 


143 


147 


151 


155 


158 


161 


161 


160 


9".. 


140 


144 


147 


151 


155 


159 


163 


166 


166 


165 


10*.. 


144 


147 


151 


155 


159 


163 


167 


170 


170 


169 



on a sufficiently large number of entrants to be con- 
vincing, was pres'ented to the Association of Life 
Insurance Medical Directors in 1908 by Dr. Faneuil 
S. Weisse. This compilation was based on the study 

S2 



THE PHYSICAL EXAMINATION. 

of the heights and weights of 59,525 insured women 
in the United States and Canada, and s'uppHed a 
long-needed standard for use in estimating female 
risks. 

By comparing this table to that prepared for men, 
it will be seen that there is a tendency for women 
to increase more rapidly in weight from age 20 to 
age 50 than for men. This period of more rapid 
increase corresponds to the reproductive period of 
women's lives, which, taken in connection with their 
more sedentary lives, would appear to be a reason- 
able explanation of the difference of the weight 
curves of the two sexes. As a matter of fact, it 
has been generally assumed by those interested in 
the influence of the bearing of children upon a 
woman's relative weight, that more overweights are 
found among women who have borne children than 
among those who have not. 

Maximum and Minimum Weights. — Having 
established a satisfactory average of heights and 
weights, it remained to determine how far the 
individual may deviate from this standard before 
entering the class of overweights or underweights. 
As the maximum and minimum weights of men and 
women do not correspond with each other they 
must be considered separately. 

Mortality. — The term "mortality" appears fre- 
quently in articles dealing with life insurance and 
an explanation should be inserted before going fur- 
ther. It means the ratio of actual deaths to ex- 
pected deaths. The actuaries have compiled a 
standard mortality table from the combined experi- 
ence of many companies by means of which the 
number of deaths in a given group of individuals 
may be calculated. If the group of individuals 
shows 1,000 actual deaths and 2,000 expected 
deaths, the mortality is 50 per cent. ; if there are 
2,000 actual deaths and 1,000 expected deaths the 
mortality is 200 per cent. The best interests of the 
companies calls for a mortality well under 100 
per cent. 

83 



INSURANCE MEDICINE. 

Men. — It has been assumed, in a general way, 
after going over much data, that a man becomes a 
moderate overweight when his weight is' more than 
20 per cent, above the standard for his age, and an 
excessive overweight when it is more than 30 per 
cent, above. Dr. Brandreth Symonds studied a 
large number of cases, however, and concluded 
that the effect of overweight is peculiarly influenced 
by tw^o factors, the amount of overweight and the 
age of the individual. This is illustrated in the 
following table in which the first column stands 
for the age period, the second for the mortality 
in moderate overweights, the third for the mortality 
in excessive overweights : 



Age 


Moderate 
Overweights 


Excessive 
Overweights 


15 to 28 
29 to 42 
43 to 56 
57 to 70 


80% 
103% 
133% 
125% 


88% 
124% 
162% 
156% 



The deduction from this table is that 20 per 
cent, overweight in a person below 29 is not an 
impairment, or at least a mild one, but that the 
mortality increases with advancing age, so that an 
excess of 33 per cent, at age 22 is almost equal to 
20 per cent, at age 45. On this basis the maximum 
weights* are indicated as the same for all ages in the 
table on page 85. 

In the case of underweights, the influence of 
age is reversed as the younger ages are the ones 
most affected, while the older ages are but slightly 
disturbed. The minimum weights, therefore, are 
given for each age period in this compact table 
which will be useful to the medical examiner. 

Women. — Overweight and underweight womten, 
measured by their own standard, show practically 
the same mortality as in the case of men. On ac- 
count of the different course pursued by the in- 
creasing weight, already referred to, as compared 
to that of men, the maximum as well as the mini- 

84 



THE PHYSICAL EXAMINATION. 

TABLE OF MAXIMUM AND MINIMUM HEIGHTS AND WEIGHTS 
FOR MEN 







Minimum for Different Ages 




Maximum 






Height 


for all 












Ages 














Age 


Age 


Age 


Age 40 






15-24 


25-29 


30-39 


and over 


5' 0* 


160 
163 


96 
98 


100 
101 


103 
104 


106 


5' 1* 


108 


V r 


166 


99 


102 


105 


110 


5' 3' 


170 


102 


105 


108 


113 


S' r 


174 


105 


108 


111 


115 


5' 5* 


178 


107 


110 


114 


118 


V t" 


182 


110 


114 


117 


122 


5' r 


188 


114 


118 


121 


125 


5' 8* 


194 


117 


121 


124 


129 


5' 9* 


199 


120 


124 


128 


133 


VXQ" 


205 


123 


127 


132 


137 


S'll* 


212 
220 


127 
132 


131 
136 


137 
142 


142 


6' 0'' 


146 


6' X" 


227 


136 


142 


146 


152 


6' 2" 


233 


141 


147 


152 


157 


(>' l" 


240 


145 


152 


157 


161 



mum weights for each age period are included in the 
following table. It will be observed that young 



TABLE OF MAXIMUM AND MINIMUM HEIGHTS AND WEIGHTS 
FOR WOMEN 



Height 


Age 
15-19 


Age 
20-24 


Age 
25-29 


Age 
30-34 


Age 
35-39 


Age 
40-44 


Age 
45-49 


Age 50 
and 
over 


4' 1* 


148 

89 
149 

90 
153 

92 
156 

94 
160 

96 
164 

98 
167 
100 
171 
102 
175 
106 
181 
109 
186 
112 
192 
115 


149 

90 
150 

91 
154 

93 
157 

95 
162 

98 
165 
100 
171 
102 
175 
106 
180 
108 
185 
112 
191 
115 
195 
118 


150 

92 
151 

94 
155 

95 
158 

96 
163 
100 
166 
102 
172 
105 
176 
108 
181 
HI 
186 
114 
192 
118 
196 
121 


151 

94 
152 

95 
156 

97 
159 

98 
164 
102 
167 
104 
173 
108 
177 
111 
182 
114 
187 
118 
193 
121 
197 
124 


151 
95 
153 
98 
157 
100 
160 
102 
165 
105 
168 
107 
174 
111 
178 
114 
183 
118 
189 
121 
194 
124 
198 
127 


152 
98 
154 
100 
158 
102 
162 
106 
166 
108 
170 
111 
175 
114 
180 
117 
184 
120 
190 
124 
195 
127 
200 
130 


153 
100 
155 
102 
159 
105 
163 
107 
167 
111 
172 
114 
177 
117 
182 
121 
186 
123 
192 
126 
197 
130 
202 
133 


154 


5' 0* 


102 
156 


5' X" 


104 
160 


5' 2" 


106 
164 


5' Z" 


110 
169 


5' 4* 


113 
174 


5' S" 


116 
179 


5' (i" 


119 

184 


5' 7* 


122 

188 


5' Z" 


126 
193 


5' 9* 


129 
199 


S'lO'' 


133 
204 




136 



85 



INSURANCE MEDICINE. 

women, as in the case of men, are not classed as 
overwei.^hts unless they are 33 per cent, or more 
above the standard, but that they are only allowed 
20 per cent, at the age of 45 or over. 

The minimum at 20 per cent, below standard 
holds good for all ages. 

Obesity an Abnormal Condition — .The expres- 
sion "fat and healthy'' is familiar and also mislead- 
ing but believed in by laymen who are usually at 
a loss to understand why some ruddy, corpulent 
individual is refused as a risk or offered a policy on 
a different plan than the one applied for. The 
prevalent idea that fat serves as a reserve fund 
to draw upon in the case of emergency or illness 
is easily disposed of when studying the wide ex- 
perience of life insurance companies. And yet 
obesity has not always been regarded as an indi- 
cation of health, for far back in the early part of 
the seventeenth century Francis Bacon came near 
to the truth in. his History of Life and Death, when 
he wrote that ''fatness in youth pointed to a short 
span of Hfe." 

In obesity, as in other morbid conditions, a given 
exciting cause has a more injurious effect in some 
individuals than in others. Thus, some persons 
however much they eat or drink never become fat, 
while in the case of others everything taken turns 
to fat though they have not particularly good appe- 
tites and are not indolent. The defective state of 
the metabolic functions which, in association with a 
relative excess of food, leads to obesity, may be due 
not only to hereditary influences, want of exercise 
and habitual disturbance of the metabolic func- 
tions from alcoholic drinks, but also occasionally to 
incidental causes which are sometimes only tran- 
sient. For instance obesity often follows typhoid 
and other fevers and accompanies certain nervous 
conditions and disorders of the sexual organs. 

Table of Diseases Peculiar to Overweights 
AND Underweights. — In order to ascertain the 
causes from which overweights and underweights 
die, Dr. Brandreth Symonds (Medical Record, 

86 



THE PHYSICAL EXAMINATION. 

September 5, 1908) studied the death claims of 
1,499 overweights and 1,078 underweights taken 
from the records of the company he represents. 
The figures obtained are compared with the entire 
mortaUty in the same company in the following 
table, and will serve to illustrate the remarks ap- 
pearing in these columns on the subjects of over- 
weights and underweights, as it gives quite a good 
idea of the malign influence at work in these cases. 



Causes of Death 



Over- 


Under- 


weights 


weights 


9.67 


9.28 


4.00 


3.06 


1.27 


1.21 


1.47 


2.04 


13.07 


24.59 


2.93 


16.98 


4.40 


5.57 


3.40 


0.65 


19.08 


12.16 


14.14 


8.47 


1.80 


0.84 


16.01 


11.69 


12.94 


8.54 


8.54 


15.78 


6.87 


12.34 


10.61 


8.54 


3.47 


0.65 


12.01 


7.42 


11.07 


5.30 


1.20 


0.47 


None 


2.04 


7.07 


5.57 


4.20 


3.43 


2.87 


2.14 


2.60 


2.50 



General 
Experi- 
ence 



General Diseases — Acute 

Typhoid fever 

Malarial fever 

Influenza 

General Diseases — Chronic 

Tuberculosis 

Cancer 

Diabetes 

Diseases of the Nervous System 

Cerebral Congestion and Hemorrhage 
— Cerebral Softening, Paralysis. . . . 

General Paralysis and other forms of 

mental alienation 

Diseases of the Circulatory System 

Organic diseases of the heart 

Diseases of the Respiratory System. . . . 

Pneumonia. ......._ 

Diseases of the Digestive System 

Cirrhosis of Liver _ 

Diseases of the Genitourinary System . . 

Bright's Disease and Nephritis 

Diseases of Skin and Cellular tissue. . . . 

Old age 

Violent causes 

Casualties 

Suicides , 

Ill defined 



8.90 

3.94 

1.24 

1.00 

19.56 

12.42 

4.18 

1.25 

17.44 

12.32 

1.30 

11.85 

10.76 

11.86 

9.03 

10.19 

1.00 

8.78 

6.66 

0.50 

1.50 

7.42 

5.21 

2.20 

3.98 



The figures represent the percentage of deaths from 
different diseases, those in the first and second col- 
umns referring to overweights and underweights 
and those in the third to the general experience of 
the company as set forth in its mortality statistics 
from 1843 to 1898. 

Effects of Obesity on Longevity. — By re- 
ferring to the table in the section on ''Maximum 
and Minimum Weights" in a previous number giv- 
ing the percentage of mortality in overweights, it 

87 



INSURANCE MEDICINE. 

is seen that the mortality rises rapidly among mod- 
erate and excessive overweights as the age ad- 
vances. Up to the age of about 29 overweight 
seems to indicate a certain hypernutrition and ro- 
bustness that is favorable to subsequent life. This 
is indicated by the figures given, from which it may 
be concluded that overweight in an individual be- 
low 29 years of age is not harmful even up to 30 
o^ 35 P^^" c^^t. above the standard, provided the 
weight does not increase with advancing years. 
This holds good for the actual weight, not the rela- 
tive weight, for the standard increases with advanc- 
ing age; so that an excess of 33 per cent, at age 
22 is practically the same as 20 per cent, at age 
45 and the subject in such a case has, therefore, 
just succeeded in keeping out of the undesirable 
class of overweights. After the age of 29 over- 
weight universally shortens life irrespective of sex 
or nationality to a marked degree, the mortality 
running as high as 160 per cent., a most excessive 
rate and one which no company conducted on safe 
and conservative lines can afford to allow. A 
slightly better mortality is exhibited in the table for 
persons between 57 and 70 years of age than for 
those between 43 and 56. This is probably due to 
more care in the selection of elderly risks. 

For very good reasons, then, no good insurance 
office will accept an individual at ordinary rates, if 
at all, whose weight bears more than a certain pro- 
portion to his height, for it is notorious that such 
persons bear accidents badly and succumb to ill- 
nesses that would be much more often survived by 
healthy subjects. Furthermore, it is agreed among 
those who have given any study to the subject that 
these risks are pooi not only because they are in 
an abnormal condition, less able to withstand shock 
and seldom reach an advanced age, but also for 
the reason that they are particularly prone to de- 
velop Bright's, heart disease, arteriosclerosis, apo- 
plexy, diabetes, and cirrhosis of the liver. 

Overweight with Excessive Abdominal 

88 



THE PHYSICAL EXAMINATION. 

Measurement. — These are particularly bad cases 
as a class. Rejection of the risk is the only safe 
plan to pursue when the abdominal measurement 
comes within a half inch or exceeds that of the ex- 
panded chest, both taken on the bare skin in ac- 
cordance with the suggestions already offered in 
these columns. The increase in mortality in these 
cases is lo to 15 per cent, over heavy w^eights with- 
out excessive abdominal measurement, and runs 
even higher when the abdominal measurement 
greatly exceeds that of the expanded chest. 

OVERW^EIGHT AND TUBERCULOSIS TENDENCY. — 

The mortality of overweights is not so poor when 
there are long lived family histories, those in which 
neither parent has died below the age of 70. While 
that of the young overweight remains good, as ex- 
pected, the gain is sufficient in mature moderate 
overweights to keep the mortality well below 100 
per cent. In all other classes, however, the mor- 
tality remains bad. 

If the family history is an average or short lived 
one, the mortality w^ill be increased. Under these 
circumstances the young moderate overweights still 
retain a fairly good mortality, but the young ex- 
cessive overw^eights show mortality increased to 
about 100 per cent. The other classes are rendered 
just so much w^orse. 

A tuberculous family history seems to have about 
the same effect as a short lived family history. In 
the young it certainly has no worse eft'ect and, on 
the whole, it may be said that overweight tends to 
counterbalance the predisposition to tuberculosis to 
such a marked degree that the amount of fatal tu- 
berculosis in these cases is less than one-quarter of 
that v/hich is found in general experience and 
hardly one-sixth of that occurring among under- 
w^eights. 

Underweight. — Underweight seems to exert no 
harmful influence as long as it does not exceed 20 
per cent, below the standard. The mortality rises, 
however, to a point where it is of consequence when 

89 



INSURANCE MEDICINE. 

the weight of applicants as a class goes below the 
20 per cent. mark. 

The bad effects of underweight are especially 
noted in the younger ages. While moderate over- 
weight is a favorable condition in this stage of life, 
underweight on the contrary is unfavorable and in 
some cases indicates a tendency to or the commenc- 
ing of disease. This is particularly true of young 
lightweight dyspeptics, this class having a decidedly 
excessive mortality rate, many of these applicants 
developing pulmonary disorders. A mortality of 
about no per cent, may be expected among young 
underweights when the weight runs from 20 to 25 
per cent, below the standard ; in other words, when 
they are moderate underweights. The rate in- 
creases as the weight falls still lower. 

As age advances, lower mortality rates are en- 
countered, so that during the ages of from 30 to 40, 
the rate may be estimated at about 100 per cent., 
which is still rather high. After the age of 40 the 
mortality becomes fairly satisfactory, as it ranges 
from about 90 to 95 per cent. General experience 
teaches that moderate underweight in those over 50 
years of age is by no means a disturbing element, 
for these are the applicants who may be expected 
to stand acute illnesses far better than the stout 
ones, and who have more chance of living to be- 
come octogenarians, finally ''drying up and blowing 
away." 

Underweight as an Advantage, — By consulting 
the table of the Causes of Death in a previous sec- 
tion on ''Obesity an Abnormal Condition,'' it is 
seen that underweights have the advantage in a 
varying degree in typhoid, malaria, diabetes, dis- 
eases of the nervous system, diseases of the circu- 
latory system, diseases of the liver and digestive 
system and diseases of the kidneys and genito- 
urinary system. It is also seen that in none of the 
cases considered did any person die of old age 
among the overweights, whereas a fairly good per- 
centage is noted for the underweights. 

90 



THE PHYSICAL EXAMINATION. 

Sir Dyce Duckworth during a discussion of rela- 
tive weights (Proceedings of The Life Assurance 
Medical Officers' Association, London, 1901), re- 
counted a story told him by Sir William Jenner ; the 
latter had been called down to the country to see 
a patient suffering from pneumonia. The family 
practitioner met him at the station to say, "I am 
afraid this is a bad case and I do not expect the 
man to pull through. He is a lean, poor, miserable, 
thin man and spitting up large quantities of blood." 
Jenner answered, *'You have told me two good 
things that make me think favorably of the case, 
because the leaner the patient and the more blood 
he spits up in pneumonia, the more likely he is 
to pull through." The patient recovered. 

Underweight as a Disadvantage. — In the same 
table the excessive rate of deaths due to disease of 
the respiratory system is evident. For instance, 
pneumonia is seen to be nearly twice as fatal among 
underweights as among overweights. This is ap- 
parently a glaring inconsistency to much that has 
been said, as it has been asserted that the prognosis 
is more serious in the overweights. The seeming 
contradiction may be explained by the assumption 
that overweights have a certain immunity from 
pneumonia but do badly when attacked, while 
underweights are more than usually susceptible to 
the pneumococcus. 

Underweight and Tuberculosis, — The association 
of underweight and a tubercular family history in 
the young is undeniably serious, the mortality run- 
ning as high as 180 per cent, in the ages below 35. 
Above that age the influence of tuberculosis de- 
pends upon the number of cases in the family, the 
mortality dropping to about 107 per cent, among 
the lightweights who have two or three or even 
more cases of tuberculosis in the family record. 

Dr. Marsh gave some facts (6th Annual Meeting 
of the Association of Life Insurance Medical Direc- 
tors) which are of interest in connection with the 
subject. While studying the deaths from consump- 

91 



INSURANCE MEDICINE. 

tion of 1,994 cases with no tuberculosis in the family 
history and 2,706 with tuberculosis in the record, 
he deduced the following facts from a considera- 
tion of the personal condition of weight in each 
class. The list of cases with untainted record 
showed nearly twice as many deaths among those 
below as among those above the average weight. 
The cases with tainted records showed a larger 
amount of consumption in both those above and 
below the average weight, but again there were 
twice as many deaths from consumption in those 
below as in those above the average weight. By 
further analysis it was plainly seen that, while the 
combination of a record of consumption in the 
family history and a personal condition of under- 
weight indicates an unusual liability to consump- 
tion, these factors differ considerably in their de- 
gree of influence. The effect of family history is 
almost insignificant compared to that of the weight 
and a good record of weight largely overbalances a 
badly tainted family history. The combination of 
the two factors indicated the maximum, and the 
absence of both the minimum of susceptibility. 

Endowment Policies for Overweights and 
Underweights. — Some of these cases, while not 
desirable for a policy on the life plan, are neverthe- 
less entitled to something better than rejection. The 
examiner, however, having given full details of the 
weight, measurements and other facts, should us- 
ually leave the question of acceptance or rating up 
to the home office. 

Overweights. — The chief factors for considera- 
tion in selecting heavyweights are the family his- 
tory, personal history, habits, occupation, residence 
and physique. If all or most of these elements are 
satisfactory, there will usually be no hesitation in 
granting a policy on the life plan to moderate over- 
weights (between 20 and 30 per cent, above stan- 
dard), and an endowment policy to excessive over- 
weights (over 30 per cent), provided the weight is 
not too excessive. 

92 . 



THE PHYSICAL EXAMINATION. 

The family history is of some importance as indi- 
cating the longevity, and a record of deaths in early 
or middle life, especially from diseases denoting 
degeneration, such as diseases of the blood vessels, 
heart or kidneys, would be an adverse factor. 

A personal history of rheumatism, gout, albumin- 
uria, glycosuria or digestive disturbances would 
add materially to the liability. 

The question of habits is of the highest impor- 
tance in deciding upon overweights, for they should 
not be accepted unless the consumption of alcohol 
is limited to a small daily amount. Total absti- 
nence is a decided point in favor of these risks. 

Occupation affects the life of an overweight, ac- 
cording as it is one requiring outdoor, active life, 
or the contrary. 

Residence would chiefly affect the risk on account 
of climate. It may be safely assumed that an over- 
weight will thrive better in a cool, bracing climate 
than in one where inertia and the debilitating effects 
of heat must be reckoned with. 

The physique will naturally have to be studied. 
The risk is better or worse according to whether 
his overweight is due to a preponderance of fat or 
muscle, and whether the abdominal measurement is 
at least a half inch less than the expanded chest. 

As overweights are liable to be cut off by the 
degenerative diseases which do not usually appear 
before 50 or 60 years of age, an endowment policy 
maturing in this period of life may be granted if 
the overweight and other conditions are not so 
adverse as to point to the danger of death at a still 
earlier age. Unfavorable overweights would be 
carried at an excessive loss, even on the endowment 
plan, and consequently would have to be balanced 
by an unusually good mortality among the normal 
policy holders, clearly an injustice. 

Underweights. — The endowment policy is not 
often appropriate for the undesirable risks in this 
class, as the risk incurred by the company is too 
immediate and not deferred as in the case of over- 

93 



INSURANCE MEDICINE. 

weights. The only intelligent plan for dealing with 
many of these cases is that by which a policy at 
a rated-up age can be issued. Occasionally, how- 
ever, companies which do not accept sub-standard 
risks or write policies with rated-up premiums, may 
issue endowment policies in individual cases in 
which there is some merit. 

The Pulse. — The pulse rate should not exceed 
90 according to the requirements of most companies. 
It should be counted for a full minute, so that the 
frequency, quality, and rhythm m.ay be determined 
with accuracy. It is advisable to observe the pulse 
and the condition of the arteries at the beginning of 
the examination before the circulation becomes ac- 
celerated through nervousness excited by the explo- 
ration of the chest. 

Rapid Pulse, — The exciting cause in the majority 
of cases of rapid pulse is pure nervousness and 
likely to occur in healthy subjects. This nervous- 
ness is so pronounced at times that it may even 
bring on syncope, and it is not a very uncommon 
event for some robust individual to faint when the 
stethoscope is applied to his chest during an exam- 
ination for life insurance. , 

At other times a pulse will become quickened in 
consequence of a hurried walk or rapid ascension of 
the stairs just before the examination. Then, 
again, the condition may easily arise as the result 
of the loss of a night's rest, a recent meal, or the 
drinking of strong coffee or tea. 

On the other hand, a persistently rapid pulse usu- 
ally indicates some organic trouble such as tubercu- 
losis, diseased kidneys, arteriosclerosis, exophthal- 
mic goiter, some early change in the brain or ner- 
vous system, or the excessive use of coffee, tea, 
tobacco, or alcohol. These conditions must be defi- 
nitely excluded even in those cases in which the 
examiner finally succeeds in getting a pulse rate at 
90 or under, but experiences difficulty in doing so. 

Slow Pulse, — A pulse rate as low as 45 or 50 is 
of no consequence unless it is associated with 

94 



THE PHYSICAL EXAMINATION. 

changes in the walls of the heart or blood vessels, or 
with some cerebral disturbance. While these condi- 
tions should be carefully excluded after looking es- 
pecially for fatty and atheromatous changes, it will 
be found that the slow pulse in most instances is 
functional in character. 

Intermittent and Irregular Pulse. — Both of these 
conditions may be attributed to the same causes 
which accelerate the action of the heart. Many of 
the companies do not regard an intermittent or 
irregular pulse very seriously, even if persistent, in 
an individual under forty years of age and within 
the normal limits of weight, provided pathological 
lesions and foci of irritation in all the organs have 
been eliminated by a rigid scrutiny of the case. 
When the pulse is intermittent or irregular in an 
applicant over 40 or one who is a light or heavy 
weight, the risk should not be recommended unless 
the examiner is successful in finding a normal pulse 
later on. 

The reluctance of the companies to insure risks 
with rapid pulse, so different from the attitude 
adopted in regard to the acceptable cases of inter- 
mittent or irregular pulse referred to in the preced- 
ing paragraph, is not difficult to understand. The 
intermittent or irregular action when purely func- 
tional, does not indicate any appreciable amount of 
extra work by the heart, whereas the never ending 
tax exacted from that organ during persistent rapid 
action is enormous. Every one would prefer to 
have the number of his heart-beats average under 
80 than at some figure close to the upper border 
line, though both rates fall within the normal limits. 
What is to be expected when the rate exceeds 90? 
A heart averaging one hundred beats a minute will - 
pulsate 14,400 more times a day than if it worked 
at the already high rate of 90. After making due 
allowance for the usual compensation for the regu- 
lar every day labor, it is quite safe to assume that 
the organ will show the effect of this continuous 

95 



INSURANCE MEDICINE. 

strain when the supreme test comes during illness or 
accident. 

Taking the Pulse. — The best time to take the pulse 
is after the questions on the application blank have 
been answered and before beginning the physical 
examination. While the examiner is plying the ap- 
plicant with questions, the latter will be seated and 
his mind will be occupied in giving the requested in- 
formation; he will, therefore, have a chance to 
recover from the effects of any unusual exertion or 
from the nervousness excited by novelty or dread 
of the examination. If the taking of the pulse is 
deferred until after the examination, it will have 
often become disturbed in consequence of excite- 
m.ent combined with the efforts called for by the ex- 
aminer. Even when this precaution has been ob- 
served the pulse may be still found too rapid, or ir- 
regular or intermittent, on account of the nervous- 
ness. In this event, the mind of the applicant must 
be diverted by drawing him easily into conversation 
on some ordinary topic; this will answer the pur- 
pose better than giving him a paper or book 
which he will apparently read, but the chances 
are that his thoughts will still be running 
on the prospects of the examination. If the last 
plan fails to succeed there is no alternative to see- 
ing the applicant again in a day or so when he will 
have probably become more accustomed to a visit 
from the examiner. It is usually better if the visit 
is made unexpectedly instead of giving the subject 
chance to become apprehensive again. 

Nervous applicants with disturbances of the 
pulse should be handled gently and receive all 
necessary attention, for if a slower and regular pulse 
is finally obtained and there is nothing more serious 
to account for the transient agitation of the circu- 
lation, they are acceptable and it would be mani- 
festly unfair and unjust to debar them from the 
privileges of securing insurance on their lives by 
sending in an adverse report without making an 
endeavor to find them in their normal condition. 

96 



THE PHYSICAL EXAMINATION. 

In order to achieve this end, the examiner should 
be willing to give extra time and not spare any 
effort in clearing up the case. 

When the examiner is finally forced to report a 
persistently rapid pulse, or one that is continuously 
intermittent or irregular in an applicant over 40 
years of age or outside the normal limits of weight, 
he should not omit to state whether this finding was 
based on one or several observations. The home 
office will invariably ask for a further examination 
in these cases when there is nothing in the report 
to indicate that the examiner has made at least one 
subsequent attempt to find a normal pulse. 

Blood Pressure. — Life insurance companies are 
recognizing the significance of abnormal blood 
pressure as a danger signal and are consequently 
becoming strong advocates for a more extensive em- 
ployment of the sphygmomanometer by their ex- 
aminers, especially since the instrument has been 
improved and adapted to the requirements of every- 
day use. The mercury type of sphygmomanometer 
is reliable if cleanliness of the instrument is ob- 
served and the proper precautions are taken when 
oxidation of the mercury occurs. The apparatus 
is bulky, cumbersome, and easily broken and, there- 
fore, only fitted for office work. It will continue, 
nevertheless, to serve the excellent purpose of acting 
as a standard for the correction of the diaphragm 
instrument which is now so widely used, and for 
this reason should be in the possession of every 
physician unless he has ready access to one in his 
neighborhood. 

The diaphragm dial type of sphygmomanometer 
has the advantage of being compact, portable, and 
easily applied. Like the aneroid barometer, it should 
be compared with a good mercury apparatus every 
three or four weeks in order to ascertain if any 
changes in the mechanism have interfered with its 
accuracy. If the readings vary from those exhib- 
ited by the standard apparatus the examiner will 
then know what allowance to make when taking 

97 



INSURANCE MEDICINE. 

observations until he can secure a readjustment of 
the instrument. 

The blood pressure should uniformly be taken 
while the applicant is seated, the coat having been 
removed and the sleeves of the underwear, if heavy, 
rolled up. The cuff, about five inches wide, should 
be placed directly over the brachial artery, and the 
rest of the band neatly wrapped around the arm. 
The inflating bulb and the sphygmomanometer 
having been attached, the air bag is inflated until the 
pulse is lost to the finger tips. The air is then al- 
lowed to escape slowly until the pulse returns to the 
wrist, and the reading is made at this point. The 
entire procedure, after a little practice, does not re- 
quire more than a few minutes, and the examiner 
will seldom if ever meet with any objections from 
the applicant. 

High Blood Pressure. — The high normal limit of 
blood pressure may be considered as lying between 
150 and 160. When the family or personal history 
is not too unfavorable and the weight of the appli- 
cant is under the maximum, a blood pressure as 
high as 160 may be looked upon as normal ; then, 
again, under other circumstances the conditions may 
be such as to justify a refusal to accept the risk if 
150 is exceeded. 

A moderately high blood pressure will often 
be transitory, due to constipation, nervousness, fear 
of the examination, recent strenuous exercise, or 
a heavy meal. The report is incomplete, there- 
fore, when a high reading is observed, until subse- 
quent examination made under more favorable con- 
ditions indicate whether or not the tension is persist- 
ently high. The several readings should then be 
recorded. 

The question of acceptance or rejection should 
be referred to the home office in cases of mod- 
erately high blood pressure. When, however, the 
pressure persists above 165 or 170 the examiner 
would better urge rejection. 

Persistent high blood pressure is a danger signal 

98 



THE PHYSICAL EXAMINATION. 

of great importance, its value being particularly 
enhanced by the diagnostic aid rendered in the early 
stages of cardiac, vascular and renal changes which 
are so frequently overlooked. While we may only 
vaguely understand the etiology of high tension, it 
is at least believed by practically all observers 
that cardiovascular-renal disease will almost surely 
follow if the cause of the high tension is not re- 
moved. 

Dr. J. W. Fisher (Proceedings of the Associa- 
tion of Life Insurance Medical Directors, October 
4, 191 1 ) in a paper on this subject stated that his 
company had made a strong effort to follow up re- 
jected cases with high blood pressure. In the course 
of his remarks he referred to 356 applicants re- 
jected with high blood pressure (average 171.73 
mm.) and one or more impairments. The impair- 
ments consisted of arteriosclerosis in 53 cases, 
heart murmur in 69, cardiac-hypertrophy in 17, al- 
bumin and sugar in 10, albumin in no, sugar in 
14, albumin and casts in 10, casts alone in 6, 
nervous symptoms in 21, prostatic disease in 5, 
miscellaneous, 41. Subsequent investigation in re- 
gard to these 356 cases showed a mortality of 171.93 
per cent. Dr. Fisher then presented a list of 366 
cases rejected for high blood pressure only (aver- 
age 170.36 mm.). The data collected later showed 
a mortality of 138.07 per cent. ; the majority of 
the deaths were due to diseases of the arteries, heart, 
and kidneys, as would be expected. These figures 
afford satisfactory and conclusive evidence that 
high blood pressure must not be ignored in the se- 
lection of risks. 

I cannot resist referring to a death claim com- 
ing under my own observation recently, as it illus- 
trates the subject so aptly. The policy holder 
had been passed previously by an able and experi- 
enced examiner, the applicant at that time being 
58 years old. Two years later he again came up 
for examination by the same examiner, and was 
again reported as a splendid risk with the single 

99 



INSURANCE MEDICINE. 

exception of a blood pressure of i68. On request 
from the home office for another reading the pres- 
sure was found to be i8o a few days later. The 
applicant was rejected at this time, and his death 
occurred nine months later from acute dilatation of 
the heart. 

Low Blood Pressure, — The lower limit of blood 
pressure is not so well understood, but it may 
safely be asserted that an applicant should be re- 
jected if his pressure is persistently under lOO. The 
low blood pressure may be a temporary one and 
should always call for subsequent readings. Un- 
hygienic conditions, too much work, too little nour- 
ishment, and poor air will give rise to lower vitality 
and consequent diminished resistance ; this in turn 
may cause a low blood pressure. Hypotension has 
been particularly noticed in tuberculosis. The 
writer was informed within a week by an official in 
charge of one of the divisions of dispensaries under 
control of the Pennsylvania State Board of Health 
for treating and preventing tuberculosis, that he 
had a record of 1200 blood pressures taken in 
tuberculous subjects. The records showed a uni- 
formly low pressure of from 100 to no, a few 
reaching 115, in incipient cases in which only the 
very first indefinite signs could be detected. In 
the later stages the pressure ran lower, reaching 
80 in advanced cases. 

Walls of the Arteries. — While taking the 
pulse, the examiner should always note whether 
there is any thickening or degeneration of the radial 
or temporal arteries. In some unaccountable way, 
the precaution is often omitted notwithstanding its 
importance. 

Full distended vessels with a moderately high 
blood pressure sometimes give rise to the impression 
that the walls are thickened. A simple way to 
eliminate this error is to subject the brachial artery 
to sufficient pressure to bring the pulsations at the 
radials to an end. This is efifected by forcibly 
squeezing that artery between the finger tips under 

100 



THE PHYSICAL EXAMINATION. 

one side of the lower end of the biceps muscle and 
the thumb under the other. The vessels then being 
empty, it is an easy matter to ascertain if the walls 
are thickened. 

Another point of importance is to examine the 
radials and temporals on both sides. It is not un- 
common to find one radial almost normal and de- 
cided thickening in the other. 

The presence of thickening or degeneration in 
any of the vessels should lead to rejection by the 
examiner. Examiners make the statement too fre- 
quently that "the arterial walls are no thicker or 
harder than is usual for a man of his age/' when 
they are reporting on applicants over 50 or 55 
years old. This statement will always call for criti- 
cism, as a life insurance company which does not 
write policies adapted to substandard risks only 
accepts applicants without pathological changes at 
any age. 

Varicose Veins. — Varicose veins are of no im- 
portance ordinarily and reference to them may be 
omitted from the report in mild cases. If they are 
marked or extensive, however, the condition should 
be fully described, and it should particularly be 
made clear as to whether or not there is any in- 
volvement of the veins other than those below the 
knee joint and whether a proper supporting ap- 
paratus is used. The examiner should also look for 
evidence of present or recent ulceration. 

The Heart. — The examination of the heart is 
often a difficult matter and will be of little value 
unless a full exposure of the chest is secured in ac- 
cordance with the scheme and diagram presented in 
a previous section on "General Methods in the Phy- 
sical Examination." When this precaution is fully 
observed, not only will the ear be assisted in detect- 
ing obscure murmurs, but it will also be impossible 
for the examiner to be deceived into hearing the 
systolic murmur which may be produced by a 
vigorous action of the heart against a thin chest 

lOI 



INSURANCE MEDICINE. 

wall covered by a thick underwear or a starched 
shirt. 

It is imperative that the place of examination be 
one in which there is complete freedom from noise 
or distraction, as the most acute ear may fail to de- 
tect a faint murmur or to differentiate a functional 
from an organic murmur under unfavorable condi- 
tions. 

It is difficult to localize the different valvular 
areas and sites of cardiac murmurs if immediate 
auscultation with the unaided ear is employed, and 
on account of this objection as well as on the 
grounds of delicacy and cleanliness, the examiner 
should always use a stethoscope for the examination 
of the heart. 

It is the purpose of the writer to confine these 
remarks to the practical points which are especially 
applicable to examination for life insurance and to 
direct the attention to the most common of the so- 
called functional murmurs which frequently have 
to be differentiated from those depending on an 
abnormal condition. The reader is referred to the 
text books for a complete account of diagnosis and 
diagnostic methods. 

One procedure, fairly well known but not often 
resorted to, for timing a heart murmur may be 
recommended. An examiner not infrequently ex- 
periences trouble in definitely deciding whether a 
murmur is systolic or diastolic, and in such a case 
he may gain assistance by comparing the time of 
the murmur with the pulsation in the radial or caro- 
tid artery. If the murmur occurs simultaneously 
with the pulsation in the arteries, it is probably sys- 
tolic ; if it is heard in the intervals between the pul- 
sations it may be regarded as diastolic. 

A few examiners have the conviction that some 
applicants with heart murmur are good risks in 
view of the apparently slight involvement of the 
valves and of the good physical condition other- 
wise. The position of the companies in this respect 
should be plainly understood. It is unquestionably 

102 



THE PHYSICAL EXAMINATION. 

true that a few subjects with defective valves attain 
great longevity, but it must be kept in mind that the 
requirements of the companies are based upon the 
great law of averages and that individual cases can 
not be recognized except when they are being rated 
up, especially as there is no reliable way of select- 
ing the few who are going to survive the others. 
The average death rate among applicants with de- 
fective valves is so heavy, notably so after the age 
of 50, that it is difficult to impose an adequate rat- 
ing on their lives. 

Companies which confine their business to stand- 
ard risks will decline all applicants indiscrimi- 
nately when the heart sounds indicate a departure 
from the normal. The guarantees in endowment 
policies are so liberal that the loading in them is not 
sufficient to cover the hazard in cardiac lesions. 
Those companies, however, which write substandard 
policies are interested in the character of the mur- 
mur and the situation of the valve involved, as they 
are inclined to consider each case on its merits and 
rate up the risk according to the prognosis of the 
particular form of heart disease in question. Every 
examiner will, therefore, be expected by the sub- 
standard companies to have a clear conception of 
the various cardiac areas and to furnish a definite 
description, so that the rates can be adjusted at the 
home office. No examiner can gauge the exact con- 
dition existing by the intensity of the murmur; a 
serious condition may be indicated by a faint mur- 
mur, and, on the contrary, a loud murmur may arise 
from a slight lesion. 

NoN-oRGANic Murmurs. — Every murmur heard 
over the heart does not point to disease of the 
valves or the orifices of the heart. Murmurs may 
therefore be classed as organic and non-organic, the 
latter class being commonly known as ''functional.'' 
It is frequently difficult to differentiate one from the 
other, and whenever the examiner does not feel sure 
as to the true nature of the sound, he should not 
hesitate to re-examine the heart on another day, es- 

103 



INSURANCE MEDICINE. 

pecially if the applicant is nervous or has been 
through some unusual mental or muscular exercise 
just before the interview. 

The company should always be given the benefit 
of the doubt when there is any indecision in the 
diagnosis. This is especially true in the so-called 
functional murmurs at the base, which have shown 
a very high degree of mortality. If any injustice 
is inflicted on the applicant by pronouncing a func- 
tional murmur to be organic, this may easily be 
rectified later; but if a murmur reported as func- 
tional turns out to be organic, an impaired risk has 
been put on the books and the policy will be beyond 
recall. 

When the examiner is convinced after an extra 
careful examination that the accidental sound is 
not significant of any pathological lesion or abnor- 
mal condition, he should omit all reference to it in 
his report. The medical officers at the home office 
will surely feel that if the murmur is important 
enough to report, they will have to reject the risk 
or request the examiner to make a further investi- 
gation. The examiner is relied upon not only to be 
exceedingly painstaking in his medical examination 
in these cases, but also to carefully ascertain the 
size of the heart and the condition of the blood ves- 
sels. 

Functional Murmurs. — The true ''functional" 
murmurs are apt to be associated with anemia or 
with some special attack upon the resources of the 
body such as physical overstrain or fever. They 
usually disappear when the underlying forces are 
removed. They are almost always systolic in time, 
and usually heard with maximum intensity in the 
pulmonic area, especially at the end of inspiration. 
They are rarely transmitted beyond the pericardiac 
region. There is no evidence of enlargement or 
significant accentuation of the 2nd sounds at the 
base. It is often difficult to decide whether these 
murmurs are organic or non-organic, but as they are 
caused by other disturbances which, even though 

104 



THE PHYSICAL EXAMINATION. 

temporary, make the risk undesirable at the time, 
the examiners task becomes the simple one of 
recommending postponement. 

Murmurs During Rapid Action. — Faint systolic 
murmurs are heard at times when the heart action 
is unusually rapid. These sounds are apt to disap- 
pear during the latter part of the examination or 
when the applicant assumes the recumbent position. 
They are possibly due to insufficient time during 
the rapid action for perfect closure of the valves — 
a temporary insufficiency. If such a murmur does 
not clear up during the first examination, it will 
usually have disappeared before a second interview 
after the applicant has had an opportunity to re- 
cover from general nervousness or excitement. 

Dynamic Murmurs, — These sounds are occasion- 
ally produced at the base by a forcible distortion of 
the chest wall, such as may occur during the exces- 
sive contraction of the muscles in certain unnatural 
postures or during efforts at extreme forced expira- 
tion or inspiration of the lungs. The same sounds 
may also be the result of heavy pressure by the 
stethoscope on exceptionally flexible chest walls. 

Cardio'Respiratory Murmurs. — This form of non- 
organic murmur is the one most frequently heard. 
These murmurs have no pathological significance 
unless caused by extensive adhesions between the 
pericardium and pleura, but are often troublesome 
to the examiner. They are usually caused, probably, 
by the forcible displacement of air in a portion of 
the free margin of the lung overlapping the heart. 
If the murmurs are accompanied by friction sounds 
denoting adhesions they should be reported, but if 
the examiners are convinced that they arise purely 
from the impact of the heart with the lungs they 
should be ignored. 

These murmurs are systolic in time in the vast 
majority of the cases, and are confined to a limited 
area. Their quality varies from that of a soft, 
breezy, blowing murmur to one closely simulating 

105 



INSURANCE MEDICINE. 

a friction sound, but as a rule it is soft and resem- 
bles that of the ordinary respiratory murmur. 

The murmurs will have some or all of the follow- 
ing marked characteristics, which render valuable 
assistance in diagnosis: 

1. There is well marked alteration in intensity 
by crescendo and diminuendo variations during in- 
spiration and expiration. 

2. They become obliterated as a rule while the ap- 
plicants hold their chests for a few seconds, either 
in a position of forced inspiration or forced expira- 
tion or when they simply arrest respiration. A true 
cardiac murmur cannot be made to disappear. 

3. They are usually heard more distinctly at the 
end of inspiration, whereas true cardiac murmurs 
become more faint at that particular time. 

4. They are usually heard over a limited area and 
seldom transmitted to the left axilla or to the back. 

5. They are not associated with hypertrophy or 
accentuation of the second sound. 

6. They may be greatly modified by pressure ex- 
erted on the thoracic wall in the vicinity of the 
murmur, both as to intensity and quality. Organic 
murmurs are but little, if any, influenced by this 
procedure. 

7. The position of the applicant will often assist 
the examiner. Almost all the cardiac murmurs are 
affected to a greater or less degree by the position 
of the body through the change in the blood-pressure 
in the region of the heart. Some organic systolic 
murmurs which are almost inaudible during the sit- 
ting or standing attitude, may easily be heard when 
the applicant lies down. The cardio-respiratory mur- 
mur will often disappear in the supine position. 

Accentuation of Heart Sounds. — Accentua- 
tion of both sounds is not uncommon in health when 
the action of the heart is forcible on account of 
nervousness. The accentuation will often disap- 
pear during the examination, but if it does not and 
no serious disturbance capable of producing it can 
be discovered, the applicant should be given the op- 

106 



THE PHYSICAL EXAMINATION. 

portunity of undergoing a re-examination before 
the final decision, when the sounds may be found 
normal. In such cases, the accentuation is of no 
moment and may be omitted from the report, but 
only after the examiner has looked carefully for 
more serious causes. When the accentuation is re- 
ported, the examiner should state explicitly whether 
or not he has made an extra effort to ascertain the 
cause and if he has any suspicion that the changed 
sound is significant of serious trouble. If the offi- 
cials at the home office are not informed that a care- 
ful investigation has been made, they will invariably 
ask for it when the mere fact that the applicant has 
an accentuation is reported. 

Pathological accentuations are met with when 
there is increase of blood-pressure in the systemic or . 
pulmonary circulation. Whenever, therefore, an ac- 
centuation of the first or second sounds is marked 
or persistent, the examiner should make a most rigid 
examination for the detection of arteriosclerosis, 
Brights, mitral disease or cardiac hypertrophy. 

Reduplication. — It is not uncommon to hear an 
occasional reduplication of the first and second 
sounds in healthy subjects. When the reduplication 
is marked or persists, however, there is probably 
some increase in blood-pressure in the systemic or 
pulmonary circulation, or changes in the walls of the 
heart, which must be carefully investigated. The 
suggestions and precautions offered in the pre- 
vious section on Accentuation, are equally applic- 
able in these cases. 

Cough and Hoarseness. — An occasional cough 
will usually be too trivial to report if a careful 
search has failed to reveal a serious cause. It may 
arise from a slight congestion of the fauces or 
pharynx, a few granulations at the back of the 
throat, or a long uvula, or it may be due purely 
to nervousness, all these conditions being inconse- 
quential. When the cough is habitual or constant, 
however, the examiner should report it in any event 
as well as making a rigid examination. 

107 



INSURANCE MEDICINE. 

Respirations. — Deviations from a normal rate 
of respiration are seldom met with in life insurance 
examining. Nevertheless the rate should always be 
taken, and if it varies much from i8 to 20 a minute 
the cause should be looked for. Labored respiration 
is encountered occasionally in applicants who are 
subject to chronic bronchitis, emphysema or 
asthma. Chronic hoarseness or huskiness should 
always be reported with the cause. 

Expansion of the Chest. — Examiners often 
refer to a large chest capacity as a valuable indica- 
tion of the manner in which the lungs perform their 
functions. In an ordinary healthy man of average 
height and build the difference between inspiration 
and expiration is about two to three inches, whereas 
in abnormal conditions there may not be an inch in 
difference. 

Great expansion of the chest is often the result 
of practice. On the other hand, deficient expan- 
sion may be encountered in individuals who, though 
robust and healthy, are stout or sedentary in their 
habits, and, through lack of practice, do not know 
how to expand their chest, especially when they are 
asked to do so. The examiner will have to give 
some instruction to such applicants before he can 
get them to show their normal capacity. 

In incipient or even in the more advanced but 
still early ages of pulmonary disease the move- 
ments of the chest may be so unrestricted that the 
expansion will afford no evidence of trouble. 

The Lungs. — Every examination of the lungs 
should be made with the chest bared in accordance 
with the suggestions and illustrations previously 
given in the section under ''General Methods in 
Examination.'* If those precautions are observed 
the examiner will be in a position to discover any 
lesion from the apex to the base. 

It must always be kept in mind by the examiner 
that he is apt to meet cases of pulmonary tubercu- 
losis in the very earliest stages when the signs are 
easily overlooked. Most of these applicants will 

108 



THE PHYSICAL EXAMINATION. 

not have any history of previous cough, hemoptysis, 
loss of weight, night sweats, or a bad family his- 
tory to put him on his guard, so that in these cases 
more than any other, probably, grave errors are 
avoided only by the exercise of the utmost care and 
thoroughness in every examination. Unless the 
examination is made in a quiet place where there 
are no distractions and the chest is properly bared, 
the signs of incipient disease in the chest will often 
escape detection. While these remarks apply to all 
applicants, they are particularly fitting to light 
weights with poor family histories and personal 
histories of dyspepsia or indigestion. 

Examiners should remember that every deviation 
in the chest from the rule does not necessarily indi- 
cate a diseased condition. The physiological differ- 
ences in the percussion note or in the respiratory 
sounds between the two sides of the chest may be 
considerably exaggerated in healthy individuals and, 
with a few, similar conditions, should not be record- 
ed after an extendeed examination has eliminated all 
possible diseased conditions. A slight prolonga- 
tion of the expiratory sound, if uniform on both 
sides and not caused by emphysema, a few crackles 
bilateral at the base and no dullness showing the 
presence of some old adhesions without thickening 
of the pleura, or the slightly harsh respiratory mur- 
mur in elderly as compared to that in younger 
people are a few of the conditions not worthy of 
reporting, always provided that extra care has been 
taken to discover more serious causes. 

Applicants who have had pleurisy are acceptable 
after a reasonable length of time has elapsed, pro- 
vided there was no suspicion of tuberculosis and 
that no thickening of the pleura remains; in these 
cases a few friction sounds may be expected. A 
full history as to the date, duration, complications, 
if any, whether it was dry, with effusion or purulent, 
and whether there was any suspicion of tuberculo- 
sis will be required, and the only one who can in- 
telligently supply these data is the attending physi- 

109 



INSURANCE MEDICINE. 

cian. The applicant is expected to furnish this 
statement from his physician. In addition to this 
the examiner must give a definite, expHcit descrip- 
tion of the physical signs remaining. 

Acute Colds. — Applicants frequently present 
themselves for examination while subject to acute 
colds. The ailment may seem too trivial to report. 
It must not be forgotten, however, that an ordinary 
cold is often the precursor to pneumonia or bron- 
chitis, especially if the applicant is indiscreet while 
under the influence of the cold. It is the duty of 
the examiner, therefore, to mention ordinary colds 
in the report and make a re-examination later, in- 
forming the home office when full and complete 
recovery has taken place. 

Thyroid Gland. — It is advisable to make a spe- 
cial search for the presence of goiter, as a small 
one is very apt to be missed. A study of this sub- 
ject shows that while these cases are not entitled to 
ordinary forms of policies, some of them are ac- 
ceptable for endowment or rated-up policies, and 
the examiner is, therefore, depended upon to fur- 
nish the following data: 

1. How long has the growth existed? 

2. Has it increased in size during the past five 
years ? 

3. Is it substernal ? 

4. Is the goitre due to simple hypertrophy or 
hyperplasia, or is it cystic or degenerating? 

5. Is it accompanied by symptoms due to pres- 
sure or to any effect on the nervous system ? 

6. Is there any exophthalmos? 

7. Does the applicant live in a healthy environ- 
ment free from scrofula and tuberculosis ? 

Abdominal Organs. — The physical exploration 
of the abdominal organs does not always yield the 
satisfactory results in diagnosis obtained from the 
examination of the contents of the thorax. Never- 
theless, it is imperatively necessary to regularly look 
for indications of certain pathological conditions. 
The examiner is urged to follow the suggestions 

izo 



THE PHYSICAL EXAMINATION. 

offered in the following sections in order to avoid 
the correspondence which the home office will surely 
call for in all cases if the particulars, where there 
is a history of abdominal pain or colic or indiges- 
tion, do not appear in the original report. 

Liver, — The liver should always be mapped out 
so that its size and location may be definitely deter- 
mined, especially when alcoholic habits are sus- 
pected. Moreover, the examiner should never fail 
to inspect the right hypochondriac and pyloric re- 
gions for the presence or after effects of gall stones, 
most particularly so when there is a history of 
abdominal pain or colic, indigestion or jaundice. 
Tenderness as well as tumefaction should be re- 
ported in every case when it is found. 

Spleen, — The mapping out of this organ is diffi- 
cult unless it is enlarged. An effort should be 
made, however, to make out the size when there is 
a history of malaria, recent typhoid or some dis- 
order of the blood. 

Appendix. — Deep pressure for the detection of 
tenderness or a tumor should be made over the site 
of the appendix in every case where there is a his- 
tory of indigestion, bilious attacks, nausea, abdomi- 
nal pains or colic. In recent cases of any of these 
disorders the home office officials will usually re- 
quire a statement from the attending physician, 
furnished by the applicant, who has the advantage 
of having observed the condition at the time of its 
occurrence and is therefore in a better position to 
state if there was any suspicion of gall stones or 
appendicitis. The examiner will save valuable 
time by anticipating this request at the time of the 
examination. When there has been an appendec- 
tomy the home office officials will want to know if 
there is any undue sensitiveness or induration of 
the scar and whether or not there are signs of 
a hernia. 

Hernia, — The abdominal, inguinal, and femoral 
regions should be looked over for the possible pres- 
ence of a hernia. Whenever a hernia is found it is 

III 



INSURANCE MEDICINE. 

most important for the examiner to ascertain if it is 
easily reducible and if the bowel is being well main- 
tained in its normal position by a properly fitted 
truss. The usefulness of the truss should be deter- 
mined, for a very large number of those worn are 
not only absolutely useless, but even harmful. When 
the hernia is easily reducible but no truss is worn, 
the examiner should explain the importance of a 
proper apparatus to the applicant and persuade him 
to procure and wear one, for most insurance com- 
panies insist on this before issuing a policy. 

The Nervous System. — It is safe to state that 
the condition of the nervous system receives too lit- 
tle attention in the great majority of examinations 
for life insurance. Specialists in nervous diseases 
have assured life insurance medical officers that they 
could almost guarantee to furnish applicants who 
w^ould pass the usual examination for life insurance 
and yet whose acceptance would prove a loss to the 
company, some within a very short time. This state- 
ment refers especially to cases of general paralysis 
of the insane and tabes dorsalis in their incipient 
stages. Examiners should always, then, have in 
mind the possibility of meeting with one of the dan- 
gerous forms of nervous trouble in its early stage 
when the signs, though most important, are slight 
and easily overlooked. 

Subjects with marked or advanced disease of the 
nervous system will rarely present themselves for 
examination. Not infrequently, however, appli- 
cants having atrophy of one or more of the extremi- 
ties with some deformity and a moderate degree of 
disability, the result of acute poliomyelitis in early 
life, will be encountered. This condition is of little 
consequence unless very marked, and the examiner's 
duty in such cases ends with including a full de- 
scription in his report and leaving the question of 
acceptance to the home office. 

The following signs and conditions are most im- 
portant : 

The Fades. — The facial aspect and general be- 

112 



THE PHYSICAL EXAMINATION. 

havior of the applicant may occasionally afford 
some information. Bell's paralysis, if present, 
would only cause postponement of the risk until full 
recovery; but the examiner should make sure that 
the condition is a peripheral one, and not due to a 
central lesion or middle ear disease. 

The Eyes. — Report inequalities of the pupils, and 
state whether they are unduly dilated or contracted. 
Marked inequality of the pupils may indicate the 
beginning of some disease of the nervous system. 
Slight differences in size may be congenital. 

Abolition of the pupil reflexes and the presence 
of the Argyll-Robertson pupil are especially impor- 
tant danger signals, but it must be remembered that 
the degree of the light has a great deal to do with 
the activity or sluggishness of these reflexes, and 
they should therefore be tested in a bright light so 
that the pupils may be afforded a chance to respond 
promptly if they have the power to do so. 

Feebleness of the reflexes seldom signifies any- 
thing of importance, but should, nevertheless, lead 
the examiner to look carefully for other signs of 
nervous disease. 

Ptosis, associated with external strabismus and 
some dilation of the pupil, is dependent upon paraly- 
sis of the third nerve. Its most frequent cause is 
syphiHs. Moderate bilateral ptosis, without the 
other manifestations just referred to, occur in hys- 
terical and neurasthenic conditions. 

The Tongue. — A fine tremor of the protruding 
tongue is usually found in the early stages of gen- 
eral paralysis of the insane, and is considered an 
important sign in this disorder by neurologists. 
This tremor is also often seen in alcoholism. 

The Gait. — Always have the applicant walk 
across the floor so that the gait may be observed. 
It may give some indication of slight hemiplegia, 
locomotor ataxia or paralysis agitans and lead to 
further investigation. 

Tremor. — Ask the applicant to extend and sepa- 
rate the fingers widely. The motions are then ap- 

113 



INSURANCE MEDICINE. 

parent. If a tremor is discovered, ascertain if it is 
due to organic disease, alcoholism, or mere nervous- 
ness. 

If the handwriting indicates a tremulous hand, 
find out if it is due to one of the causes already 
mentioned or simply to illiteracy and lack of famil- 
iarity with the pen. 

Patellar Reflexes. — When the knee jerk is really 
absent, rejection of the risk will usually follow. 
Failure to obtain the patellar reflex, however, is 
often the fault of the applicant or the examiner. 
The applicant should sit with the knees loosely 
flexed at a blunt angle, with the muscles relaxed. 
When the subject is stout or heavily muscled, a 
better result may be obtained by having him sit on 
a table with the legs hanging loosely. If no con- 
traction is obtained on striking the tendon, have the 
applicant lock the fingers of the hands together and 
give a quick pull upon them and then let go at a 
given signal. As the examiner gives the signal he 
should strike the patellar tendon at the same mo- 
ment. Through this simple stratagem the appli- 
cant's mind is diverted and he relaxes the muscles 
of the thighs and legs which had previously been 
held too rigid. 

The exaggerated knee-jerk may occur in the 
early stages of peripheral neuritis and of lesions 
of the spinal cord. It is also found in more ad- 
vanced cases of nervous dis'ease which would not 
be likely to come before an examiner for life in- 
surance. It should be kept in mind that the knee- 
jerk may be somewhat exaggerated in nervous sub- 
jects and signify nothing abnormal. 

BahinsMs Reflex,- — This important sign should 
be looked for when the examiner suspects some 
nervous disorder. Bare the applicant's foot and 
draw the blunt end of a pencil along the inner side 
of the sole from heel to toe with moderate pressure. 
If the great toe cocks up toward the shin, Babinski's 
reflex is present and may mean serious organic dis- 
ease of the upper motor neurons. 

114 



THE PHYSICAL EXAMINATION. 

Romberg's Symptom. — Test the power of the ap- 
plicant to balance, by asking him to bring his feet 
together toe to toe and heel to heel, and to close his 
eyes. Inability to preserve his balance is a valu- 
able sign in early tabes. 

Occupation Cramps, — The most familiar of these 
is the troublesome ''writer's cramp.'' They should 
not be a bar to insurance, although it is advisable to 
report them to the home office with full particulars 
after more serious disorders have been excluded 
by the examination. 

The Eyes. — Reference to the pupillary reflexes 
and nervous affections of the eyes w411 be found in a 
previous section on the Nervous System. 

A large percentage of applicants have ordinary 
errors of refraction, usually corrected by glasses, 
which are not of sufficient consequence to report. 
Actual blindness of both eyes should be reported, 
as such risks are rejected. In the case of a recent 
enucleation, the examiner should ascertain the cause 
and whether the other eye is in danger through sym- 
pathetic affection. 

Double cataract will usually call for rejection of 
the risk until after complete recovery from an op- 
eration for extraction and a fairly good restoration 
of the sight. Unilateral cataract is not commonly 
considered a bar to insurance, if of long standing, 
if no recent increase in size, if no operation is con- 
templated, and if the other eye is normal. A catar- 
act of recent appearance leaves more doubt as to 
the way it is going to conduct itself and whether or 
not the other eye will be invaded, than one of 
longer standing. 

Subjects with chronic trachoma are not regarded 
as satisfactory risks and severe cases may meet with 
refusal. This condition, therefore, should be fully 
described. 

These are the affections the examiners are liable 
to meet, and, after making a full report, they would 
better leave the final decison to the home office. 

The Ears. — Chronic deafness without any dis- 



INSURANCE MEDICINE. 

charge during the past one or two years will not 
be a bar to insurance, though it is customary for 
most companies to charge a slightly increased pre- 
mium owing to the greater danger incurred in the 
streets. Deafness should, therefore, be reported 
with the following details : If not total, can the 
applicant hear conversation and ordinary street 
sounds without the aid of artificial appHances? Is 
there any existing disease of the ear? Is there any 
history of discharge? If so, give date of last dis- 
charge. 

There is a slight difference of opinion among the 
companies in regard to the acceptance of subjects 
with present or recent otorrhea. It may be gener- 
ally stated, however, that these risks are insurable 
if there is no family taint of tuberculosis and fa- 
vorable answers are received to the following 
queries : 

Is the disease unilateral? 

Is the discharge ever purulent, bloody or foul 
smelling ? 

Any pain or tenderness? 

Furthermore, as the examination of the middle 
ear is a difficult matter and only of value when 
made by one with experience in this line, the ap- 
plicant will be expected to furnish a certificate from 
a competent aurist comprising answers to the fol- 
lowing questions in the case of present or recent 
otorrhea : 

Size of perforation in the drum? 

Site of perforation (upper, middle or lower por- 
tion — good drainage of the cavity depends upon the 
site of the opening) ? 

Any granulations, polypi, caries or involvement 
of the mastoid cells ? 

The Skin. — The diseases of the skin usually 
coming to the notice of the examiner are eczema 
and psoriasis. These troubles are of no importance 
unless they are persistent and invade large areas, 
in which case they are often the outward expres- 
sion of some considerable dyscrasia or constitu- 

ii6 



THE PHYSICAL EXAMINATION. 

tional disturbance that may lead to lesions of the 
viscera and vessels at some future time. For this 
reason a company may believe it advisable to limit 
the applicant to an endowment or rated up policy. 
The examiner, then, should always give the nature, 
duration, severity, parts effected and the extent of 
surface involved. 

Whenever a skin lesion presents itself, the ex- 
aminer is expected to go into the case very care- 
fully for the purpose of excluding syphilis, and he 
should also state that he has done so in his report, 
whether there is any suspicion or not, so that there 
will be no doubt in the minds of the staff at the 
home office. 

Scars. — The origin of scars should always be as- 
certained and reported. The possibility of tubercu- 
losis, syphilis or wounds received in some fracas 
should be kept in mind while making this inquiry. 

Mouth, Teeth and Tongue. — These parts 
should be looked at, as some indication of digestive 
disturbances, syphilis, or disease of the nervous sys- 
tem may be discovered which will suggest the ad- 
visability of further investigation. The applicant 
should always be requested to protrude the tongue, 
so that any tremor of the organ may be detected. 

Deformities. — ^The loss of a finger or toe is only 
worth recording as a mark of identification. In the 
case of an amputation, the point of amputation, 
date, cause and present condition of the stump 
should be noted in the report. Always report the 
fact if the applicant uses artificial limbs, crutches 
or a cane on account of an amputation of the lower 
extremity or any other disability. 

Curvature of the Spine. — The insurance value 
of a risk with spinal curvature depends on two 
conditions : 

1st — ^Was the cause of deformity tubercular or 
nontubercular ? 

2d — Is the deformity sufficiently marked to cause 
undue pressure upon the viscera ? 

The antero-posterior spinal curvature (kyphosis) 

117 



INSURANCE MEDICINE. 

is commonly the result of Pott's disease or tubercu- 
losis of the spine, especially when angular. The 
angularity is often better felt than seen. These 
cases should be accurately described, as they will 
usually be rejected at the home office. 

Lateral curvature (simple lordosis and scoliosis) 
will not cause rejection in most companies unless 
too marked. The authorities at the home office will 
not get a clear idea of the amount of deformity un- 
less the examiner gives the amount of deviation 
from the median line by ^actual measurement as 
well as other details. Some form of policy will 
probably be issued to subjects with lateral curva- 
ture if the displacement of the bony structures is 
not enough to cause excessive pressure upon the 
vital viscera. 

Hip Joint Disease, — Having given a full history, 
the amount of shortening should be ascertained by 
actual measurement and, at the same time, an in- 
spection should be made for the presence of scars 
which would indicate that an abscess formed when 
the disease was active. When possible to obtain a 
statement from the physician who treated the dis- 
ease in its early stage this may have to be furnished 
in order to find out if there was any suspicion of 
tuberculosis. 



Ii8 



Chapter IV. 

THE URINE. 

The chemical examination of the urine is a mechan- 
ical process and there is no justification for inac- 
curacies, especially as the examiner is not asked to 
make a scientifically complete uranalysis for the dis- 
covery of small abnormalities as an increase 
or decrease in the phosphates, chlorides, urea, or 
uric acid, the practical significance of which is 
usually not definitely known. In fulfilling the re- 
quirements that are called for, however, the com- 
panies expect the examiners to use the utmost care 
and precision, as otherwise the analysis will be 
valueless. The standard methods described in the 
following lines are simple and reliable, and there 
will be no danger of the occurrence of mistakes if 
they are faithfully followed. 

Urination. — Symptoms of disease of the urinary 
organs, such as frequent or painful micturition, per- 
sistently turbid or otherwise abnormal urine, should 
be carefully investigated. 

When the applicant acknowledges to urinating at 
night, it is essential to learn the frequency, amount 
pas'sed, and the reason. In men over 50 it may be 
due to prostatic disease. On the other hand, it may 
be occasioned by drinking considerable water or 
some other beverage before retiring or may be due 
merely to habit. Close questioning will usually 
elicit the desired information. 

How to Procure Urine. — The urine must be 
voided in the presence of the examiner. When, 
however, the applicant is a woman, the examiner 
must be near enough to be morally certain that the 

119 



INSURANCE MEDICINE. 

urine is passed by the applicant. He should also 
notice whether the urine, when returned to him, is 
in the container presented by him to the woman for 
that purpose and is still warm. A report must 
never be based upon the analysis of a specimen 
which has been brought or sent to the examiner. 

How to Report Abnormal Ingredients. — If the 
first specimen presents an abnormality, either in 
specific gravity or by the presence of albumin or 
sugar, the examiner should obtain and analyze a sec- 
ond specimen before reporting; then if the second 
specimen also presents the abnormality, he should 
include the analysis of both specimens in the medi- 
cal report and forward it to the home office in the 
usual way. If, however, the second specimen pre- 
sents no abnormality, a third specimen should be 
obtained by the examiner and sent to- the home 
office properly preserved and vouched for, the 
analysis of the first and second specimens being 
included in the examination report. In addition to 
this, the medical department will usually call for 
still another sample to be mailed to the home office 
in a container which should be sent to the examiner 
and which carries in it an antiseptic to act as a 
preservative. 

In all instances when albumin or sugar has been 
found in the urine, a statement signed by the appli- 
cant as to whether or not he has been under treat- 
ment or on restricted diet for albuminuria or 
glycosuria during the past six months, should be 
furnished if the examiner finally decides to recom- 
mend the risk. 

These requirements are practically the same in 
all companies, thou^^h th/^re may be an occasional 
slight variation 

Apparatus. — The only apparatus needed is: 

1. Two test tubes, five or six inches long and 
one-half to three-quarters of an inch in diameter. 

2. Urinometer of a reliable make, preferably 
Squibbs. Test it frequently in distilled water; if 

120 



THE URINE. 

it rests at the zero mark it may be considered ac- 
curate. 

3. Alcohol lamp or Bunsen burner. The latter is 
always ready and a time saver. 

4. Litmus paper, red and blue, of a reliable make. 
This should be kept in bottles so that it will not be 
affected by volatile acids and alkalies. 

5. Glass pipettes. 

6. Filter paper and a glass funnel. 
The only reagents needed are: 

1. Nitric acid, chemically pure. 

2. Strong official acetic acid. 

3. A solution for testing sugar. 

Technique of Uranalysis. — Avoid mistakes by 
exercising painstaking care at each step and taking 
sufficient time, especially if there is the slightest 
doubt. 

Keep all apparatus scrupulously clean, and wash 
the beakers and tubes thoroughly before and after 
using for each specimen of urine. 

Remove all stains and smears from the test tubes. 
Nitric acid will remove tenacious stains from the 
inside of the tubes. 

During the process of boiling the tube may be- 
come sooty, or cloudy from the salts remaining 
after the evaporation of moisture from the outer 
surface of the tube; in either case the tube should 
be gently cleansed with a damp cloth before in- 
spection of the contents. 

Do not employ the same tube for both the al- 
bumin and sugar tests, as the reagents employed 
for detecting sugar often leave deposits on the in- 
side of the tubes which are difficult to remove. 

Small amounts of albumin readily escape detec- 
tion in semi-opaque, dirty tubes. 

Turbid urine must be filtered before making the 
chemical analysis ; otherwise traces of albumin will 
not be discovered. It may be necessary to filter the 
specimen several times, but if it still remains turbid 
after this procedure, bacteria or pus is probably 
present and a fresh specimen should then be ob- 

121 



INSURANCE MEDICINE. 

tained. Do not filter with the aid of powdered talc, 
French chalk, charcoal or any other powder. These 
insoluble powders often remove the turbidity, but 
they also remove considerable amounts of albumin 
and sugar. 

Tests should not be made or read by artificial 
light. 

Reaction. — This is ascertained by the litmus pa- 
per. Acids turn blue litmus paper red, while alkalies 
turn red litmus paper blue. Occasionally a urine 
will be amphoteric, in which case it turns red blue 
and blue red. This condition is of no significance. 

Specific Gravity. — The urinometer must float 
clear in the urine and not come in contact with the 
walls of the tube. The limits adopted by most 
companies are i,oio and 1,030, and if the specific 
gravity falls outside of this range the examiner is 
expected to obtain another specimen and subject it 
to a complete chemical analysis. 

Tests for Albumin. — The use of the albumoscope 
or horismanscope is not recommended. 

Do not use that portion of the urine to which the 
heat test has been applied, for the cold nitric acid 
or contact test. 

Always hold the tube against a black background 
by a well-lighted window in order to observe ac- 
curately the result of the test in either method. 

Having thoroughly cleansed the tube and filtered 
the urine, if necessary, the following tests are to be 
used, as they are the most reliable and convenient : 

Heat Test. A clean test tube is filled two-thirds 
full of clean urine. If not acid it should be made 
so by the addition of one or two drops of acetic acid 
or dilute (10 per cent.) nitric acid. Boil the upper 
half of the urine for half a minute at least, holding 
the tube by its lower end and taking care that it 
does not become sooty. Then hold the tube against 
a black background by a well-lighted window. 

If there is no sign of turbidity in the upper boiled 
part as compared with the lower cold part, there is 
no albumin in that specimen. 

122 



THE URINE. 

If there is any turbidity in the upper boiled part, 
add two or three drops of nitric acid. If the tur- 
bidity entirely and promptly clears up, it was prob- 
ably due to earthly phosphates and it can still be 
said the urine is free from albumin. 

If any turbidity, no matter how slight, remains 
after the addition of nitric acid, it indicates the 
presence of albumin or nucleo-proteid, probably the 
former. To differentiate between these, the ex- 
aminer must resort to Heller's test. 

If the heat test gives absolutely no reaction, it 
can safely be said that the urine contains no albumin 
and it will not be necessary to resort to Heller's 
test. 

Some recommend the addition to the urine of 
one-sixth its volume of a saturated salt solution be- 
fore adding any acid or applying heat. 

Heller's Test. Pour half an inch of pure, 
colorless nitric acid into the tube. The test tube 
is then held at an angle of more than 45 degrees 
while a quantity of clear urine is allowed to flow 
from a pipette slowly down the side of the tube 
until an inch of it overlies the acid. If this is 
carefully done there will be no mixture of the urine 
and acid. When albumin is present it will be in- 
dicated by a sharp, white ring at the line of con- 
tact between the acid and the urine. 

This white zone may form very slowly when 
the albumin is present in a small amount, and it 
is therefore imperative for the tube to be set aside 
carefully for at least fifteen minutes in order to 
get a positive reaction with traces of albumin. 

A diffused ring or cloudiness beginning above 
the line of contact indicates urates or nucleoproteid, 
but not albumin. This diffused ring need never be 
confused with the sharply defined albumin ring at 
the line of contact. 

A positive reaction w^th both the heat and Hel- 
ler's test indicates without doubt that albumin i^ 
present; it is equally certain that no albumin is 
present if Heller's test carefully carried out ac- 

123 



INSURANCE MEDICINE. 

cording to the directions gives a negative result, 
even though a cloudiness remains after application 
of the heat test. 

If the person has been taking any oleoresin, 
such as cubebs, copaiba, etc., this will also cause a 
white ring at the junction of the liquid, but it can 
easily be differentiated from albumin by means of 
the heat test. 

Another method, requiring considerable care to 
prevent mixture of the urine and acid and not ad- 
vised for this reason, is the following : Take a per- 
fectly clean, dry test tube and place in it about one 
inch of urine; allow concentrated nitric acid to flow 
slowly from a pipette down the side of the inclined 
test tube. Wait fifteen minutes, then look very 
closely for a wide band or cloud denoting albumin 
just above the junction of the acid and the urine. 

Tests for Sugar, — If there is much albumin in 
the urine, it should be removed before testing for 
sugar, as it may interfere with the reaction. This 
may be done by rendering the urine faintly acid by 
the addition of two or three drops of acetic acid 
and boiling. Then filter the specimen to remove 
the coagulated albumin. The urine is then ready 
for the sugar test. 

The urine must be fresh, as a small amount of 
sugar might be lost by decomposition. 

The best reduction tests for the examiner in the 
field are those in which the salts of copper and 
bismuth are used, but as other substances besides 
sugar possess the power of reducing copper and 
bismuth salts, the reduction tests are only of nega- 
tive value. The absence of reaction, then, indicates 
the absence of sugar, but the presence of a reaction 
simply shows that some reducing agent, probably 
sugar, is present. 

In order to determine whether or not the reduc- 
ing agent is sugar, the examiner must resort to the 
fermentation test, this being the only reliable posi- 
tive test. The phenyldrazine test is no longer re- 
garded as positive, as it has been discovered that 

124 



THE URINE. 

the characteristic crystals may form through the 
influence of other substances besides sugar. Fur- 
thermore, the characteristic crystals are sometimes 
not produced even when sugar is present. 

Fehling's Test. The two solutions should be 
kept separately in well-stoppered bottles in the dark. 
When the reagent is wanted, equal quantities 
should be taken from each bottle and well mixed. 
The resulting liquid is a transparent dark blue. 
One dram of this should be put in a test-tube and 
gently boiled. Then urine should be added, a few 
drops at a time, and the boiling continued. If 
sugar be present, the solution assumes an opaque 
color, and soon a dense, yellowish red sediment falls 
to the bottom. Should no change occur, urine must 
be slowly added until its volume equals but does not 
exceed that of the reagent. After the urine is 
added, boiling should not continue more than half 
a minute, for the reaction is prompt. Simple dis- 
coloration of the reagent does not indicate sugar, 
nor does the formation of a grayish cloud which is 
due to the precipitation of earthy phosphates. 

Haine's Test. The formula for this solution 
was devised for the purpose of furnishing a reagent 
that is not liable to spontaneous decomposition. 
Late experience, however, has demonstrated that 
it will not always keep indefinitely as was formerly 
supposed, and that it is important for the examiner 
to observe, after boiling the test solution and be- 
fore adding the urine, whether or not any of the 
copper salt has been reduced. If the solution re- 
mains clear on boiling, it has not deteriorated. 

In testing with this solution put about i dram in a 
test-tube and gently boil. Then add the suspected 
urine, drop by drop, up to eight drops — not more — 
while continuing to boil. The same reaction occurs 
as with Fehling's solution. If much sugar is pres- 
ent it will show with the first drop or two, but in no 
case should more than eight drops of urine be added. 

Nylander's Test. This is the best solution in 
which bismuth is used as a reagent. It is a modifi- 

125 



INSURANCE MEDICINE. 

cation of Boettger's test and consists of two grams 
(30 grains) of bismuth subnitrate and four grams 
(i dram) of Rochelle salt (potassium sodium tar- 
tarate) dissolved by the aid of gentle heat in 100 
ex. (26y2 fluid drams) of a 10 per cent, solution of 
sodium hydrate. It has the advantage over Fehl- 
ing's and Haine's solutions of not spoiling and it 
is not so readily reduced, being unaffected by 
chloral, pyrocatechin or glycosuric acid. It is, 
however, less delicate than Fehling's, detecting only 
i/io per cent, of glucose and that imperfectly, but 
that is good enough for all clinical work. The most 
delicate method of applying the test is to fill a test 
tube about half full of urine and then add about 
one-third as much of the reagent, mixing them well 
together. Boil the upper portion, and if sugar is 
present a dark brown or black precipitate of metallic 
bismuth and bismuth suboxide is produced. Boiling 
should be maintained for one minute if necessary. 
The formation of a light-gray cloud is not signifi- 
cant, as it is simply due to earthy phosphates. 

Fermentation. When one of the reduction 
tests previously described fails to show the presence 
of sugar, the result may be regarded as final and no 
corroborative test is called for. If, on the other 
hand, a reaction is obtained with any one of them, 
the strong probabilities are that it is due to sugar 
and the examiner must assume this to be the case 
until he proves by means of the fermentation test 
that no sugar is present and that the reaction was 
due consequently to some other agent. In this test 
the sugar present in the urine is fermented by the 
aid of ordinary yeast and the carbon dioxide given 
off is collected and measured. As fermentation 
proceeds, the gas collects in the upper part of an 
inverted tube, driving out the urine. The simplest 
and best way of applying the fermentation test is by 
means of Einhorn's saccharometer. The following 
precautions must be observed: 

(a) The temperature should preferably be be- 
tween 80° and 90° F. 

126 



THE URINE. 

(b) While fermentation is going on, the tem- 
perature must never rise above 115° F., for yeast 
cells are killed at that point. 

(c) The temperature should not be constantly 
below 60°, for fermentation proceeds very slov^ly 
or not at all below this point. 

(d) In every case a control test should be made. 
This should be done with a normal urine, known 
not to contain sugar. This control is of great value, 
for as all yeast contains a little glucose, the presence 
of a bubble of gas at the top of each tube shows 
the yeast is fermenting properly, and at the same 
time the examiner can see whether or not more 
gas is forming in the suspected urine. 

(e) In a doubtful case at least twenty-four hours 
should elapse before declaring that the test gives no 
reaction. 

(f) The urine must be free from antiseptics or 
preservatives. 

Resume of the Steps in a Chemical Uranalysis. — 
Note whether clear or turbid ; if the latter, find out 
to what it is due. 

Take the specific gravity. If above or below 
the limits prescribed by the company interested, get 
another specimen and subject it to a complete chem- 
ical analysis. 

Test the reaction with both blue and red litmus 
paper to determine whether it is acid or alkaline. 

Test for albumin by the heat test. If this gives 
absolutely no reaction, the examiner may safely say 
that the urine contains no albumin. If it gives any 
reaction at all, test the urine then by Heller's test, 
letting it wait at least fifteen minutes if necessary. 
The use of the heat test is advised at first, for it re- 
quires only a few minutes and a negative reaction 
with it is conclusive. The examiner should state 
distinctly in his report to the company what he finds 
with each test if they give different reactions, even 
if he thinks that the reaction is due only to necleo- 
proteid. 

Test for sugar by one of the reduction tests, 

127 



INSURANCE MEDICINE. 

Fehling's, Haines', or Nylander's. If no reaction 
is obtained, it is certain that the urine contains no 
sugar of clinical importance. If a reaction is ob- 
tained with one of these tests, it should be corrob- 
orated by fermentation, as a positive reaction with 
the latter is conclusive. If, however, a negative 
reaction occurs with fermentation and a positive 
reaction with a reduction-test, the examiner should 
state the full findings in his report to the company. 

Microscopical Examination of the Urine. — 
The clinical significance of red blood cells, leuco- 
cytes, and renal casts depends largely upon the 
number of these bodies, whether they persist or 
not in being present, and the cause; also the age, 
personal history, and condition of the applicant. A 
few red blood cells or leucocytes will often be over- 
looked if they are not indicative of some serious or 
chronic trouble. Considerable judgment is required 
in determining the value of renal casts as a sign 
of present or impending disease. 

Mucous cylindroids must be distinguished from 
true casts, and this differentiation is quite difficult 
at times. While it is possibly true that they appear 
as the result of some very slight irritation of the 
renal tissues, their presence is usually disregarded! 

Hyaline casts are often found in the urine of 
healthy persons, probably as a result of errors in 
diet or drinking, or exercise. Under these condi- 
tions, they should quickly disappear. A too fre- 
quent reappearance, even under these circum- 
stances, should arouse suspicion. On the other 
hand, these bodies are the first to appear in dis- 
ease as an indication of commencing irritation or 
congestion of the renal tubules. 

Granular casts, if present, will almost always 
lead to rejection on account of the well-known fact 
that they indicate more advanced lesions in the 
renal tissues. 

The medical officers cannot fairly estimate the 
significance of these doubtful bodies in the urine, 
unless the reports are made by men whose ideas 

128 



THE URINE. 

are ha^;monious with those held at the home office. 
All microscopical examinations are therefore made 
either at the home office by men trained for this 
work and with the most approved apparatus and 
facilities, or at certain points by selected repre- 
sentatives who have taken a course of instruction 
at the headquarters of the companies. 

Microscopical examinations of the urine are 
required only in cases in which there is some indi- 
cation or when the amount of insurance is large 
enough to warrant this extra precaution. 

Note. — The methods and technique of uranalysis 
presented here are, aside from a few modifications, 
recommended in its book of instructions to exam- 
iners by the company which the writer represents, 
and have been found most reliable and simple after 
many years of experiment and practice. 



129 



Chapter V. 

THE EXAMINATION OF WOMEN. 

Medical examiners are apt to experience a feeling 
of timidity when the applicant happens to be a 
woman and to apprehend that they will incur her 
displeasure if they ply all the pointed and direct 
questions which appear in the examination blank, 
or if they insist on a complete examination. If the 
same woman were to come to one of these examin- 
ers as a private patient, even though an utter 
stranger, he would not hesitate to put her through 
a process of rigid catechism in regard to her strictly 
personal affairs and most intimate relations in so 
far as they would have any connection with the case, 
and furthermore, to request her to submit to a 
physical examination perhaps even more searching 
than that required when she is applying for life in- 
surance. Allowing for the difference in the circum- 
stances, there is no good reason why a physician 
should not carry out his task with equal thorough- 
ness in both cases. It may be depended upon that a 
woman will feel ill at ease and uncomfortable if the 
examiner gives any indication by his demeanor that 
he has a delicate and unpleasant mission to per- 
form and that he fears he will wound her suscepti- 
bilities. If, on the other hand, he goes about his 
work in an easy, polite and matter-of-fact way, 
courteously but with veiled firmness, insisting on 
the fulfillment of all the requirements of the com- 
pany, he will not create any occasion for embarrass- 
ment or annoyance. Good judgment in forming 
and putting the questions is also necessary; as, for 
instance, it might be unwise to bluntly ask a young, 

130 



THE EXAMINATION OF WOMEN. 

refined, delicate-minded, and unmarried woman if 
she is pregnant. Yet this query appears in the 
blank and must be answered in every case, whether 
the woman is married or single, and the information 
may be easily obtained by securing from her a full 
history of her menstruations and the date of the last 
one. The same line of questions will bring out the 
fact as to whether or not she has ever borne children. 
When answers brought out in this way have been re- 
corded, however, the applicant should be asked to 
read that part of the report carefully and to state 
if they are correct. Modesty, then, may and should 
be thoughtfully regarded, but this consideration 
should never be allowed to interfere with thorough 
work. 

It is especially important to observe the follow- 
ing admonitions: 

1. The examiners are depended upon to make 
both the inquiries into the past history and the 
physical examination with scruplous care and not 
to take anything for granted. They will, indeed, 
soon find that close and persistent questioning is 
often necessary in order to elicit a full, definite 
history, owing to the failure of the average woman 
to realize that she becomes party to a legal con- 
tract when she signs an application for insurance 
or to grasp the strict business principles involved in 
the making of a contract, and also to her natural 
tendency to avoid the subject of the diseases and 
ailments peculiar to her sex. 

2. The examiner should adhere strictly to the 
rule which forbids the presence of a third person 
(even the husband) while he asks the questions on 
the examination blank. The object of this restric- 
tion is to secure free answers without any restraint 
or influence. During the physical examination, 
however, it is proper to have a friend or relative 
present if the applicant desires it. 

3. The applicant should be previously instructed, 
when possible, to arrange her clothing in such a 
way as to insure ease, facility, and thoroughness in 

131 



INSURANCE MEDICINE. 

the examination. A loose gown of some light 
weight material will answer the purpose admirably. 
At least, if she has not done this, she should be 
requested to remove her corsets and other heavy 
apparel which would interfere with the inspection 
of the chest and abdomen. 

4. The chest measurements should be taken hori- 
zontally immediately below the axilla, avoiding 
the mammae. The abdominal measurement should 
be taken at the waist line, as well as at the level of 
the umbilicus, as requested in the examination 
blank, care being taken not to include the crests of 
the ilia. If the abdomen be large below this line, 
the examiner should ascertain whether it is merely 
adipose and pendulous, or whether there is a possi- 
bility of tumor or pregnancy. The proper methods 
of measuring are fully discussed in a previous sec- 
tion on "Height, Weight, and Measurements." 

5. The urine must be passed at the time of the 
examination. If this is not possible the examiner 
must obtain it later himself; in no case should he 
permit it to be sent or brought to him. The ex- 
aminer can easily obtain the urine under circum- 
stances which assure him it was voided by the ap- 
plicant, by arranging to have it passed in his own 
office or even at her residence while he temporarily 
adjourns to the next room. The urine should be 
warm when presented to him and in the container 
which he gave her for that purpose. 

6. A pregnant woman may be examined accord- 
ing to the rules of some companies, usually pro- 
vided she has previously been through a normal 
labor. 

7. The mortality among insured women is so high 
when any element of speculation enters the case 
that the home office staff will carefully criticise an 
application made by a wife for the benefit of her 
husband, or by an elderly woman for the benefit 
of adult children. In these cases, therefore, the ex- 
aminer should be especially cautious and report con- 

132 



THE EXAMINATION OF WOMEN. 

fidentially to the medical department any suspicious 
circumstances connected with the case. 

8. The mortality among young unmarried women 
who are insured is high, and is largely due to tuber- 
culosis. For this reason the examiner is called upon 
to be very thorough in his examination of the lungs 
of these applicants. 



i|3 



Chapter VI. 

COMPLETION OF THE EXAMINER'S 
REPORT. 

Errors and Omissions. — The examiner should 
review every answer in his report before forward- 
ing the papers to the company so as to assure him- 
self that there are no omissions or incomplete an- 
swers. If all necessary information is supplied 
and errors revised at this time, both the examiner 
and the company will be spared the trouble and an- 
noyance of further correspondence, and the agent 
will not incur the danger of losing his business 
through delay which might have been avoided. It 
is most important for the agent to receive the policy 
for delivery as soon as possible after the examina- 
tion has been made on account of the liability of 
the applicant to change his mind, or to become in- 
fluenced by the arguments of busy rivals who are 
always in the field. 

A record of the omissions and incomplete an- 
swers for each examiner has been kept at the home 
office of the writer's company, and it shows that 
many examiners who are undoubtedly well qual- 
ified and competent cause considerable correspond- 
ence, trouble, and delay by not properly completing 
their reports. 

Alterations and Erasures. — The medical ex- 
aminer's report should be free from ditto marks, 
alterations, interlineations, or erasures ; further- 
more, it must be kept in mind that a dash does not 
constitute an answer to a question. An application 
is an actual legal contract and must be drawn up 
with the requirements of the law in mind. Correc- 

134 



COMPLETION OF THE EXAMINER'S REPORT. 

tions are, however, unavoidable at times, and, when 
demanded, should be made by drawing a line in 
ink through the words at fault; the correction 
should then be duly attested by the initials of the 
examiner with date of the attestation. This pro- 
cedure is especially important in the blanks of com- 
panies operating under the laws of a State which 
require that photographed copies of applications 
be attached to the policies. 

Confidential Information. — Whenever an ex- 
aminer declines or postpones an applicant he should 
mail a confidential letter to the company at once, 
giving his action and the cause for it. Further- 
more, even if he recommends the applicant for in- 
surance, the examiner should inform the company 
by means of a confidential letter as to anything 
brought out in the course of the examination which 
may affect the insurability of the risk, even though 
the examiner is not certain that this information 
will prevent the issuance of insurance to the appli- 
cant. Many companies supply their medical ex- 
aminers with blanks and addressed envelopes to be 
used for this purpose. 

This procedure gives the examiner an oppor- 
tunity to express his private opinion of the real in- 
surable worth of the applicant to the company. It 
happens, not infrequently, that an examiner is re- 
luctant or even unwilling to incorporate certain in- 
formation in his report for the reason that it might 
hurt his own interests or those of a friend or pa- 
tient if these facts were known in his community. 
The examiner in such cases may be fearful that the 
secret would be divulged were it to come to the 
eyes of the agent or manager in writing. It is the 
manifest duty of an examiner, however, to give the 
company the benefit of his knowledge of every- 
thing of an adverse nature affecting the risk, and 
he can do this quietly and without any publicity 
by means of a confidential letter. The items which 
render the risk questionable may occur in the f am- 

135 



INSURANCE MEDICINE. 

ily history, in the personal record of diseases or in- 
jury, or in the matter of habits or environments. 

In order that these letters may prove of value to 
the company they must be written and mailed im- 
mediately after the examination and investigation 
of the applicant is completed. The information 
contained in such letters will always be treated by 
the company as strictly confidential, and the ex- 
aminer need not, therefore, hesitate to furnish facts 
of any nature. 

Confidential letters are especially important for 
the reason that the examiner's report is sometimes 
lost and the company has then no record of the 
adverse information unless notified by one of these 
letters. Another reason is that in the case of com- 
panies which allow their agents to receive the re- 
port from the examiner, some agents will occa- 
sionally suppress or destroy an unfavorable report 
in the hope of getting a more complacent examiner 
to recommend the risk. 

The Recommendation. — The report having been 
completed to this point, the examiner is called upon 
to recommend the acceptance or rejection of the risk. 
The form of recommendation varies according to 
the requirements of different companies, and may 
be divided into the following classes: 

I, In most blanks, a definite "yes" or "no'' is 
required, and any deviation from this simple mono- 
syllabic affirmative or negative answer will usually 
complicate the matter. 

The recommendation should be based largely 
upon the physical condition of the applicant, there 
being very few exceptions to this rule. 

The question of family history should always be 
left to the consideration of the home office officials 
who give decisions on hundreds of family records 
daily and are therefore more familiar with the sub- 
ject. When an examiner qualifies the recommenda- 
tion for acceptance of the risk by some such phrase 
as "barring the family history," he makes an un- 
necessary suggestion, as the family history is sup- 

136 



COMPLETION OF THE EXAMINER'S REPORT. 

posed to be already presented in full detail in 
the application for the study of the home office au- 
thorities. It will complicate the situation still more 
if the examiner recommends rejection on account 
of the family history. It would seem a simple mat- 
ter for an approving officer at the company's head- 
quarters to regard such an answer as final, ignoring 
the negative answer and accepting the risk when he 
is satisfied with the family history, disagreeing with 
the examiner as to the bearing of this part of the 
report on the insurability of the applicant. This is 
not a safe practice, however, as the writer can tes- 
tify from the experience of his own company in 
several cases in which the examiners advised re- 
jection of the risks on the ground of unfavorable 
family histories. As the family histories recorded 
were satisfactory, it was assumed that the exam- 
iners had overestimated the value of, what appar- 
ently seemed to them, adverse features, and issu- 
ance of the policies was approved in each of these 
cases. Death claims were presented a year or so 
later and it was then learned that each of the ex- 
aminers had been in possession of the knowledge 
of some serious impairment which they would not 
allow to appear in writing for politic reasons and 
supposed that they were discharging their obliga- 
tions to their company by basing their rejections 
on grounds of a trivial nature. If they had sup- 
plemented their report by sending the missing in- 
formation to the home office, according to the sug- 
gestions in a previous section on "Confidential Let- 
ters," they would have fulfilled their duty and pre- 
vented the unfair losses to the company. There 
was no redress in these cases as it was decided by 
the company that the rejection of the examiners, 
even though the real cause for their action did not 
appear in the reports, should not have been over- 
ruled without further investigation. No application, 
then, should be finally approved at a hom e offi ce un- 
til a recommendation of rejection based on appar- 

137 



INSURANCE MEDICINE. 

ently insufficient reasons has been fully explained 
by subsequent correspondence with the examiner. 

The personal history, also, should be left for the 
consideration of the home office after being fully 
recorded in the report. Occasionally there will be 
some remaining effect of a recent or even remote 
illness, in which case the examiner may recommend 
rejection as, in such a case, he is justified in his 
refusal on account of the present physical condi- 
tion. 

The habits of the applicant may usually be left 
to the judgment of the medical directors, although 
they should be reported very carefully in all cases. 
If, however, the examiner is aware from his per- 
sonal observation that the applicant is a bad risk 
on account of frequent intoxication or the use of 
drugs, he will be justified in recommending rejec- 
tion. 

The term "fair risk" or "average risk" should 
never be used instead of the concise "yes" or "no" 
in recommendations in this class. Companies do 
not limit their business to writing policies for ath- 
letes and those who enjoy the perfection of good 
health ; they are quite ready to accept good average 
risks, knowing that the latter will live out their ex- 
pectancy as well as the former. When, however, 
the examiner qualifies his endorsement by the elas- 
tic and vague terms "fair" and "average," it is sus- 
pected that, in his opinion, the risk is not quite up 
to the standard and this doubt has to be cleared up 
through correspondence. The examiner has the ad- 
vantage of inspecting the applicant personally and 
must make up his mind definitely whether or not 
the physical examination justifies the insuring of 
the risk. 

2. In a few companies the examiners are asked 
to recommend action according to whether in their 
opinion the risks are "good," "fair," or "poor." 
When this classification is required, the examiners 
are usually expected to rate the risks according to 
physique, general appearance and general record 

138 



COMPLETION OF THE EXAMINER'S REPORT. 

of family vitality. The drawback to this form of 
recommendation is that there is apt to be a dis- 
crepancy between the estimates of different ex- 
aminers. 

3. The examiners are not required to make any 
recommendation by some companies. This plan has 
certain advantages, especially to companies which 
issue rated up policies to sub-standard risks. These 
companies will probably write some form of policy 
even though it will differ from the one applied for, 
and it would, therefore, be manifestly inexpedient 
to ask the examiner to advise rejection in the case 
of impaired physical conditions. In this class, the 
examiners are expected to set forth fully the facts 
in the personal and family records and to state the 
results of the physical examination, so that the 
medical department at the home office may draw its 
own conclusions. 



3 3^ 



Chapter VIL 

FRAUDULENT PRACTICES. 

The possibility of fraud and deception should be 
constantly kept in mind, as it is not uncommon to 
meet with some of the following practices: 

Fraud Practised by the Applicant. — The 
fraudulent practices discussed in the following par- 
agraphs are those usually originating with the 
applicant : 

Age. — The age is understated at times by appli- 
cants in order to derive the benefit of a lower pre- 
mium. Insuring a considerable number of risks 
for premiums computed for younger ages will in- 
volve an unwarranted loss to a life insurance com- 
pany, as the premium for each age is based on the 
Experience Table of Mortality. If the examiner 
doubts the accuracy of the given age he should 
communicate this fact to the home office. It must 
not be forgotten, however, that if several men were 
commissioned to judge the age of a certain indi- 
vidual, there would almost always be a difference 
of several years between the highest and the low- 
est estimates. An examiner might, therefore, do 
an injustice to an applicant were he to report a 
discrepancy between the given and the apparent 
ages unless it amounts to at least five years. 

Suppression and Distortion of Facts. — Suppres- 
sion, as well as distortion, of facts constitutes mis- 
representation, as every application for life insur- 
ance calls for a declaration in some form from the 
applicant that he has disclosed full and accurate in- 
formation in regard to his personal and family his- 
tory. According to law an undue concealment or 

140 



FRAUDULENT PRACTICES. 

nondisclosure of facts and circumstances which 
one party is under legal or equitable obligation to 
communicate, and which the other party has a right 
to know, establishes a misrepresentation or breach 
of warranty and will give sufficient grounds to a 
company to cancel the policy provided the delin- 
quency is important enough and is discovered within 
a reasonable length of time after the date of issu- 
ance, a period which may be generally stated as two 
years. When, then, there is the slightest doubt as 
to the veracity of an applicant, the examiner will do 
a good deed to him as well as the company by inti- 
mating the extent of the possible penalty in diplo- 
matic but unmistakable terms. 

Concealment of Physical Defects. — Dishonest ap- 
plicants, assisted at times by corrupt agents, dis- 
play considerable inventive skill in preventing the 
discovery of physical impairments by the exam- 
iners. Examples of these attempts are innumerable 
in the history of life insurance. Space forbids a 
description of all of them even if it were possible. 
A few of the instances which have come to the writ- 
er's notice may serve as illustrations of the import- 
ance of close scrutiny in every examination. 

An application was recently received in which the 
applicant had persisted in remaining in a sitting 
position during the examination, his excuse being a 
badly fitting shoe hurting his foot. The suspicions 
of the home office officials were aroused by a report 
from another source, and the examiner, being re- 
quested to re-investigate, had to admit with chagrin 
that he had been fooled by a subject with spinal 
disease. If this examiner had taken the precaution 
of observing the gait, as he should do in every case, 
he would have saved himself considerable morti- 
fication. 

In another recent case, a well-trained examiner 
had occasion to confess himself tricked by an appli- 
cant who vigorously chewed gum to hide the evi- 
dence of facial paralysis. 

A chronic axillary abscess, which had not been 

141 



INSURANCE MEDICINE. 

acknowledged during the questioning, nearly 
escaped detection. The applicant was a clergyman 
and his statements would have been accepted with- 
out hesitation by the majority of examiners. Un- 
fortunately for him, however, the examiner who 
had charge was a very cautious and inquisitive in- 
dividual who insisted on making the examination 
with a completely bared chest, and this led to the 
discovery of the abscess. 

Fraud Practised by the Applicant and 
Agent. — The agent and applicant have been discov- 
ered in league, the former having coached the lat- 
ter to conceal certain facts or set them forth in 
a misleading way. 

In other cases, the agent succeeds in getting pos- 
session of an adverse report from an examiner 
which should have been sent to the home office. The 
agent then takes the applicant to another examiner 
with the hope that he will not discover the defect 
or wuU be complacent enough to overlook it. If 
such a report is surrendered to the agent, not- 
withstanding the fact that such a procedure is both 
ill-advised and dangerous, the examiner should at 
once immediately notify the home office of the name 
and date of birth of the applicant and the impair- 
ment, so that the fraud may be prevented. 

Substitution is difficult but is attempted at times. 
It is especially easy for this practice to be followed 
among the many undesirable aliens who are swarm- 
ing into the United States. Two conspiracies of 
considerable magnitude have come into the writer's 
experience and both happened among that class of 
people. The practice of substitution is not, how- 
ever, always confined to members of this low grade 
of society. It, therefore, behooves the examiner to 
keep his eyes open and report any suspicious cir- 
cumstances to the home office. 

Fraud Practised by the Agent. — The agent 
may attempt to exert an evil influence on the ex- 
aminer by requesting or even demanding him to 
modify or omit some adverse statement from the 

142 



FRAUDULENT PRACTICES. 

report. At other times, the agent will try to pre- 
vent the carrying out a part of or even the entire 
physical examination. No examiner worthy of the 
name would submit to such overtures, but it is 
wise to remember these injunctions, as some of the 
unscrupulous agents are most plausible and per- 
sistent in their arguments. 

The agent or any other person should never be 
permitted to procure the urine from the applicant, 
no matter how much trust and conjSdence the ex- 
aminer has in those individuals. 

An agent will sometimes change the report after 
it has left the hands of the examiner. It is a good 
rule, even when the agent is trusted and honest, to 
invariably send the report directly to the local man- 
ager or home office. 

Fraud Practised by the Examiner. — To the 
credit of the profession it may be asserted that 
bribery and collusion are rare occurrences among 
medical examiners. Such practices have happened, 
however, sufficiently often to bring about the en- 
actment of laws in some of the states for shielding 
the companies against fraudulent conduct on the 
part of the examining physicians, whereby the wil- 
ful making of a fraudulent statement in an appli- 
cation for life insurance is made a misdemeanor 
punishable by fine or imprisonment. 

Fraud Practised by Policyholders. — This does 
not concern the medical examiner directly, and ref- 
erence to the crimes perpetrated by policyholders for 
defrauding life insurance companies is made only 
as a matter of interest. Suicide by persons who 
wish to provide for their families at once is prac- 
tically prevented by the insertion of a clause in the 
application, which provides that suicide within a 
certain time after the issuance of the policy shall 
not make the policy a claim against the company, 
whether the suicide was sane or insane. Murder of 
a person insured in favor of the murderer is an- 
other means of fraud. Mysterious disappearance, 
usually arranged to present the probability of sui- 

143 



INSURANCE MEDICINE. 

cide, is the most successful and common form of 
crime adopted for this purpose, but as the companies 
must be on their guard under suspicious circum- 
stances, such schemes are usually foiled. 



144 



INDEX. 

PAGES 

Abscess 12,52 

Abdomen, Measurements of 76, 77, 78 

Abdominal Measurement, Overweight with Excessive 88 

Abdominal Organs, Examination of the no 

Age, Apparent 13 

Albumin, Tests for 122 

Heat and Nitric Acid 122 

Heller's 123 

Albuminuria 43 

Alcohol, Use of 55> 56 

Anemia 33 

Apoplexy 28 

Apparent Age 74 

Appearance, General 12 

Appendicitis 38,39 

Appendix, Examination of the in 

AppHcation, a Contract 14 

Arteries 13 

Asthma 38 

''Average" Risk, the Term 138 

Babinski's Reflex 114 

Biliousness. 38 

Bladder, Diseases of 44 

Blood Pressure. 97 

High 98 

Low 100 

Blood Spitting 34 

Bronchitis 36 

Chest, Expansion of the 108 

Measurements of 76, 77 

Circulatory System, Diseases of 1 1, 30 

Colds, Acute no 

Colic 40 

Renal 43 

Completion of the Examiner's Report 134 

Concise Answers, Importance of 71 

Confidential Information 135 

Letters to the Company 135 

Convulsions 28 

Cough 33» 107 

145 



INDEX. 

PAGES 

Deformities 14, 54, 117 

Diarrhea 39 

Digestive System, Diseases of the ii>37 

Diseases Peculiar to Overweights and Underweights 87 

Dizziness 27 

Dropsy 32 

Drugs, Use of 60 

Dyspepsia 32 

Dyspnea 32,38 

Ears, the 13 

Diseases of the i3> 53 

Examination of the 115 

Epilepsy 27 

Examination, Physical 12, 67 

Place of 7 

Privacy during . 9 

Promptness in 8 

Quietude during 9 

Time of 7 

Examining, Method in 9 

Eyes 13 

Examination of the 112,115 

Facies, the 112 

Fainting 27 

**Fair," the Term 73» 138 

Family History 12, 62 

Tuberculosis in 63 

Fevers, Infectious 1 1, 47 

Figure 72 

Fistula 42 

Fraud by Concealment of Physical Defects 141 

by Suppression and Distortion of Facts 140 

in Regard to Age 140 

Practised by the Applicant 140 

Practised by the Agent 142 

Practised by the Applicant and Agent 142 

Practised by the Examiner 143 

Practised by the Policyholders 143 

Fraudulent Practices 140 

Gait, the 113 

Gallstones 38, 41 

General Appearance 72 

General Build 74 

General Considerations 4 

Genito-Urinary System, Diseases of the 11, 42 

Glands, Suppuration of 12, 54 

Glands, Swelling of 12, 54 

Goiter 1 10 

Gout 12, 49 

146 



INDEX. 

PAGES 

Habits .12,55 

Headaches 30 

Heart, Examination of the 13, loi 

Murmurs, Cardio-Respiratory 105 

Dynamic 105 

from Rapid Action 105 

Functional 104 

Non-Organic loj 

Pain in Region of 331 

Sounds, Accentuation of 106 

Reduplication of 107 

Height, Measurement of 7 S» 7^ 

Heights and Weights for Men, Table of 89 

Hematemesis 39 

Hematuria 44 

Hemoptysis 34 

Hemorrhoids .«. 42 

Hernia 13, 55, iii 

Hip Joint Disease 118 

Hoarseness 33, 107 

Hydrocele 45 

Hygienic Surroundings 10, 17 

As to Locality 19 

As to Place of Business 18 

As to Residence 18 

Effects of 18 

Incomplete Answers i S> 134 

Incomplete Information 14, 134 

Indigestion 38 

Infectious Fevers 1 1, 47 

Insanity 28 

Introductory Remarks i 

Jaundice 40, 74 

Judgment 4 

Keeley Cure 60 

Kidney, Diseases of the 43 

Diseases of the Pelvis of 44 

Movable 43 

Lead Poisioning 28 

Limbs, Loss of 54 

Liver, Diseases of 13, 40 

Examination of the 1 1 1 

Longevity, Effects of Obesity on 87 

Lungs, Examination of the 13, 108 

Malaria .11,45 

Measurements of Chest and Abdomen i3»75»76,77 

147 



INDEX. 

PAGES 

Measurements of Women 77 

Methods in Examining 9 

Moral Hazard 10 

Mortality 83 

Mouth, Diseases of 14 

Examination of the 117 

Movable Kidney 43 

Nervous System 13 

Diseases of 11,26 

Examination of the 112 

Neurasthenia 29 

Neuritis 29 

Nose, Diseases of 12, 53 

Obesity, an Abnormal Condition 86 

Effects of on Longevity 87 

Occupation 10, 20 

Occupation Hazard 21 

Omissions in Answering Questions 15, 134 

Operations 54 

Overweight in Men 84 

Table of. 84 

Overweight in Women 84 

Table of ^ 85 

Overweight with Excessive Abdominal Measurement. 88 

Endowment Policies for 92 

with Tuberculosis Tendency 89 

Overweights 92 

Overweights and Underweights, Diseases Peculiar to 87 

Pallor 73 

Palpitation 31 

Paralysis 28 

Patellar Reflexes 114 

Pelvis of the Kidney, Diseases of 44 

Personal History 11,25 

Physical Examination, Arrangement of Clothing in 69 

General Methods of 12, 67 

Privacy during 9, 68 

Quietude during 9» 69 

Plethora 74 

Pleurisy 36 

Pneumonia 36 

Prostate Gland, Diseases of. .' 44 

Ptosis 113 

Pulse, the 13, 94 

Intermittent 3i>95 

Irregular 31, 95 

Rapid 94 

Slow 94 

Taking the 96 

148 



INDEX. 

PAGES 

Pupillary Reflexes 113 

Purpura Hemorrhagica 32 

Race 13' 75 

Recommendation, the 136 

Renal Colic 43 

Report, Alterations in the Examiner's 134 

Erasures in the Examiner's 134 

Errors in the Examiner's 134 

Omissions in the Examiner's 15, 134 

Respirations 108 

Respiratory System, Diseases of ii» 33 

Rheumatism 12, 47 

Acute 32,48 

Chronic 49 

Romberg's Symptom 115 

Sallowness 74 

Scars 117 

Scrofula 1 2 , 54 

Skin 14 

Diseases of 12, 53 

Examination of the 116 

Spine, Curvature of 117 

Spleen 13 

Examination of the iii 

Sugar, Tests for 124 

Fehling's Test for 125 

Haines' Test for 125 

Nylander's Test for 125 

Siuistroke 30 

Surgical Operations 12, 54 

Syphihs 12, 51 

Tact 4 

Tape Worm 42 

Teeth, The 14, 117 

Thyroid Gland 13,110 

Tongue, The 14, 113, 117 

Tremor 30, 113 

Tuberculosis in Family History 63 

Pulmonary ' 36 

Tuberculous Tendency, Overweight with 89 

Tumor 53 

Unclassified Diseases 1 1, 45 

Unconsciousness 27 

Underweight 89, 93 

and Tuberculosis 91 

as an Advantage 90 

as a Disadvantage 91 

149 



INDEX. 

PAGES 

Underweights, Endowment Policies for 92 

Ulcer 12, 52 

Uranalysis, Technique of 121 

Resume of the Steps in 127 

Ureter, Diseases of 44 

Urethra, Stricture of 45 

Urination 119 

Urine, Apparatus for Examination of the 120 

Examination of the 119 

How to Procure 14, 119, 132 

How to Report Abnormal Ingredients in the .... 119 

Microscopical Examination of the 128 

Reaction of 122 

Urine, Specific Gravity of 122 

Varicose Veins 33. loi 

Vertigo 27 

Weight 13^ 75, 80 

Weights, Maximum and Minimum 83 

Women, Examination of 9,14, 130 

Measurements of 77 

Writer's Cramp 28 



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